Mentors to the Max

Jan Pflugfelder, RN, MS, knows what it takes for Native American students to succeed in nursing school: sheer determination plus culturally sensitive support from faculty and administrators who serve as mentors, cheerleaders, sympathetic ears—and sometimes even baby-sitters.

Pflugfelder, a doctoral student at Loyola University School of Nursing in Chicago, supplies all these things and more as director of the American Indian Students United for Nursing (ASUN) program at Arizona State University in Tempe. ASUN is a federally funded program designed to recruit and retain Native American students into the university’s nursing school by providing them with financial assistance and mentoring. It receives some of its funds from the Indian Health Service (IHS).

A number of other colleges and universities throughout the United States offer similar support programs for Indian students, under a variety of different names (see “A Master Plan for Mentoring”). Although many of these programs are new, they are already starting to make an impact in increasing the number of Native American nurses in this country—a population that has been drastically underrepresented in the profession.

One study conducted in 2000 showed that only 0.3% of all registered nurses in the U.S. were Indian, a percentage that hasn’t changed in 10 years. Similarly, the federal government’s most recent National Sample Survey of Registered Nurses (March 2000) indicates that only 0.5% of the RN population is American Indian/Alaskan Native, a figure that remains unchanged since the previous survey in 1996.

So critical is the need for Native American nurses who can provide culturally competent patient care in Indian communities that the National Indian Nursing Education Conference devoted its 10th annual gathering to this issue. Held in March 2000, the conference was co-sponsored by the Nursing Division of the IHS and the University of South Florida (USF) College of Nursing’s Recruitment and Retention of Native Americans in Nursing program, which is part of the Center for Native American Nursing Studies at the USF’s Tampa campus. “Our job is monumental,” says Joan Gregory, PhD, a member of the Lower Muskogee Creek tribe and director of the 21/2-year-old center.

As a group, Indians tend to be isolated from the rest of society, whether they’re living on a reservation or in an urban area. Many exist at or below poverty level and often they are undereducated. Therefore, directors of nursing schools say, many Native American young people find it hard to imagine themselves having successful careers.

Those who do succeed in nursing are often drawn into their careers by dedicated mentors. Many of these mentors are themselves Native Americans who have returned to their communities to help where the need is greatest. Indeed, nursing schools around the country—from large universities to small tribal colleges—are discovering that Indian nurses mentoring other Indian nurses is crucial to both attracting and retaining Native American students.

Whatever It Takes

Once Indian students enroll in a nursing school program that’s especially geared to their needs, they begin to see what value they can have as trained professionals, Pflugfelder emphasizes. That’s why she and her counterparts at other schools immerse themselves in their mentoring roles, doing whatever it takes to guide Indian students through their educational training and into successful nursing careers.

At Oglala Lakota College, a tribal college in Pine Ridge, S.D., this means arranging for Indian nursing students to be mentored by faculty in the Native American Scientist Program at South Dakota State University (SDSU)’s College of Nursing in Brookings.

“Our students collect data on chosen populations, which teaches them how to do research,” explains Margaret Hart, RN, director of Oglala Lakota’s nursing program. “They receive college credit and a stipend, which is very helpful because these students don’t have much money,” adds Hart, who is a doctoral student in nursing at Barry University in Miami.

The Oglala Lakota nursing students get an additional perk, according to Roberta K. Olson, RN, PhD, dean of the SDSU College of Nursing. “After being in the scientist program and graduating from Oglala Lakota,” she says, “they’re in a good position to enroll in an upward mobility program in nursing at our university.”

But to get students to that point often means “being willing to do things that a typical academic administrator wouldn’t do,” says Pflugfelder. For example, she maintains an open-door policy that permits her 45 students, most of whom are Navajo, to contact her by phone any time of the day or night—and they often do. Many of them are parents and may suddenly find themselves in need of someone to take care of their children while they take an exam.

“We tell them to bring the baby in [to our office] or we go to their home,” notes Pflugfelder, who collaborates with a social worker. “We get to know the students’ families. We’re like family to them, like a respected aunt or grandmother.

“I’ve learned that first-year students particularly need someone who’s sensitive to their needs,” she continues. “It can be really overwhelming for them to adjust to city life, not knowing anyone and taking challenging classes.”

Pflugfelder and her team do a lot of what she terms intrusive monitoring. “We have students sign an agreement stipulating that we can contact any faculty member to help a student in need, whether it’s a problem with paying the rent or receiving a low test score. We don’t wait until they’re put on academic probation. We do early intervention—aggressive advisement—which allows us to jump right in there at the first sign that a student is having difficulty.”

In what may seem a time-consuming procedure, Pflugfelder keeps track of every phone call and visit from each Indian nursing student to make sure the students are staying in regular contact with her and her staff.

“If they don’t come in to see us enough, that’s a red flag,” she comments. “So we go to their home and ask, ‘What’s going on? Is there a problem?’” Fortunately, Pflugfelder doesn’t have to travel far. Most of the ASUN students, who on average are older than other students and have at least two children, live on campus. Their kids all go to the same school, so they can network for child care. They get to know each other through regular meetings and in the classroom, where Pflugfelder makes sure that there are at least two Indian students in every class.

To encourage camaraderie among the ASUN students, Pflugfelder helps organize an annual traditional Indian potluck meal, attended by faculty, staff, students and friends. When the students receive their nursing degrees at the end of the school year, Pflugfelder hires a drum group or singer to perform a special honor song.

These grads have accomplished no small feat, Pflugfelder points out. “Nobody gets into this program unless he or she meets the requirements. And our expectations are high.”

Traditional Beliefs, Modern Technology

Beverly Patchell, RN, CNS, project director of the American Indian Nursing Student Success Program at the University of Oklahoma in Oklahoma City, turns to traditional Indian rituals to help her students through the school’s challenging nursing curriculum.

“I might try to set up a ceremony as they come in [to the program] that will spiritually empower them to do the things necessary to succeed in nursing school,” says Patchell, who is of Cherokee and Creek origin. In her private practice, she helps Native American students reduce stress in a way they’re familiar with—by using flower and gem essences to improve energy fields in the body.

“While Western medicine takes a mechanistic view of the body—i.e., that everything’s going to break down over time—Indians take a synergistic approach,” she explains. “We include animals, plants and stars, all the energies of the universe. We look at the unseen, such as the spirit, to create healing.”

Patchell also offers a class called “Tribal Pathways to Health and Healing,” which focuses on the customs and cultures of the eight or so tribes represented at the nursing school. It is designed to help the students learn about each other’s traditions so they feel more connected.

Several nursing schools that offer mentoring programs for Indian students use a student retention model invented by Jan Pflugfelder. Appropriately, her model is represented by the medicine wheel, which Native Americans use to symbolize the circle of life. Each of the wheel’s four directions—north, south, east and west—correlates with the four elements of life: spiritual, emotional, mental and physical. Superimposed on the wheel is a dream catcher, an Indian symbol representing the complexities of life. “Everything is circular, non-linear, in the Indian tradition,” Pflugfelder says.

“All our activities revolve around the medicine wheel,” agrees Jacque Dolberry, RN, MS, director of the nursing department at Salish Kootenai College, a tribal school serving the Flathead Reservation in Pablo, Montana. The college’s nursing students receive assistance from a federally funded program called Pathways to Indian Nursing Education (PINE).

“Whatever we do [in the PINE program] becomes cultural,” states Dolberry. “Our events open with prayers, and our whole curriculum looks at the differences between modern culture and traditional American Indian beliefs.”

In the first quarter of the academic year, Dolberry takes students to a culture center to learn about hide tanning and stick games such as shinny, which is like soccer. PINE students come from 23 tribes in 12 states, “so we try to introduce them to the practices of different tribes,” she says.

Much of the learning at Salish Kootenai’s school of nursing is interactive, because “Indians like to learn through hands-on activities,” Dolberry adds. “We like to know the big picture, rather than just details presented in a classroom setting.” Because it is a custom in many tribes to avoid looking someone directly in the eye as a show of respect, hands-on learning also makes it easier to adapt to Indian students’ style of communication. Dolberry credits this interactive approach with boosting the nursing program’s student retention rate to about 75%.

In the PINE program, even the mentoring process reflects the circle-of-life concept. Dolberry trains Indian nursing students who have completed their first year to be peer mentors to incoming students. These student mentors also visit local middle schools, she says, to “help plant the seed [of nursing as a career choice] and show young people how to develop a healthy lifestyle.”

At the University of South Florida, which draws Native American nursing students from rural areas, Gregory offers courses through the Internet and on video to make it easier for students to stay in the program. She also formed a support group for Native American students called E-ma-ni-cep, which means “caring” in Creek.

Remarkable Results

High visibility in the Indian community is crucial to maintaining a steady stream of Indian students in a nursing program, according to Barbara Dahlen, RN, MS, FNP. A member of the Turtle Mountain Chippewa tribe, Dahlen is assistant coordinator of the Recruitment/Retention of American Indians in Nursing (RAIN) program at the University of North Dakota (UND) College of Nursing in Grand Forks, where she obtained her degrees.

Dahlen and her staff spend much of their time visiting and advising at tribal colleges, so that graduates of these schools can make an easier transition to nursing programs at universities like UND. “Community colleges play a key role in our success,” she says.

Dahlen, who attended a mission school as a child, feels that coming from the same background as the students she’s trying to recruit is a plus, both for her and for potential students: “[Seeing what I’ve achieved] makes them feel that they can be successful, too.”

After applying for and receiving federal funding to start RAIN, she held out for an Indian support staff and worked hard to enlist the whole-hearted support of the university’s administrators. “Everyone has to buy into the program to make it a success,” she maintains.

As of May 2001, UND’s nursing program has graduated 113 Native Americans—96 in the bachelor’s program and 17 in the master’s program.

“That’s significant,” Dahlen emphasizes, “because prior to 1994, there were no Indians with master’s degrees in nursing. We also have a 93% student retention rate; generally, 60% to 70% is considered good. Our board rate is also high: 90% of our RAIN students pass the licensing exam on their first try. That’s extremely significant. You don’t see results like that at a lot of other programs that target minority students.”

The most lasting proof of these mentoring programs’ success is that their graduates snare good nursing jobs, often in the Native American communities from which they came. And they continue to stay in touch with the nurses who mentored them through their nursing education.

“They never leave us,” one director of nursing explains. In this case, that’s a very good sign.

A Master Plan for Mentoring

By Pam Chwedyk

All of the mentoring programs for American Indian nursing students mentioned in this article are part of a larger umbrella program called Native American Nursing: Caring for Our Own. This project is sponsored by the Midwest Alliance In Nursing Initiative (MAIN), an organization formed in 1980 by a group of nurses from academic and service settings to collaborate on mutual nursing interests.

Funded by a grant from the federal Health Resources and Services Administration (HRSA)’s Division of Nursing, Caring for Our Own is designed specifically to prepare Native American nurses to care for Native American people. Its goal is to help Indian students complete degrees in nursing by assisting them academically and (to a limited extent) financially, with a strong emphasis on mentoring.

The project currently consists of nine nursing school “support programs,” each of which is funded by the Indian Health Service and custom-tailored to the needs of the particular school’s students. The participating schools are:

* Arizona State University, College of Nursing (Tempe, Ariz.)—American Indian Students United for Nursing project (ASUN)
* Oglala Lakota College, Nursing Department (Pine Ridge, S.D.)
* Salish Kootenai College, Nursing Department (Pablo, Mont.)—PINE program (Pathways to Indian Nursing Education)
* Sisseton Wahpeton Community College, Nursing Department (Sisseton, S.D.)
* State University of New York at Buffalo—Family Nurse Practitioner Program
* University of North Dakota, College of Nursing (Grand Forks, N.D.)—RAIN program (Recruitment/ Retention of American Indians Into Nursing)
* University of Oklahoma, College of Nursing (Oklahoma City, Okla.)—American Indian Nursing Student Success Program
* University of South Florida, College of Nursing (Tampa)—Recruitment and Retention of Native Americans in Nursing program
* University of Wisconsin at Eau Claire, College of Nursing.

On a national level, the National Alaska Native/American Indian Nurses Association (NAN/AINA) is very actively involved with the Caring for Our Own project. In addition, NAN/AINA is in the process of forming a student chapter within the association, which will be headed by Mechem Slim, a nursing student at Georgetown University in Washington, D.C. One of Slim’s goals for the new student membership section is to produce a national newsletter, written by and for Native American nursing students.

For more information about Native American Nursing: Caring for Our Own, contact: Roberta K. Olson, RN, PhD, Project Director, South Dakota State University College of Nursing, Box 2275, Brookings, SD 57007-0098, (888) 216-9806, [email protected]. Or contact the National Alaska Native/American Indian Nurses Association at (888) 566-8773.