It is the Indian Health Service (IHS) and it remains the nation’s largest employer of American Indian and Alaska Native nurses. But regardless of race or ethnicity, if you’re a nurse who has a strong desire to experience different cultures, work with medically underserved communities, fight minority health disparities and reap the benefits of a career that offers chances to advance to leadership roles, working for the Indian Health Service may be just the opportunity you’ve been looking for.
In 1921, Congress passed the Snyder Act, which established the Indian Health Service as the primary federal health care provider and health advocate for Indian people. It’s a role the agency has continued to play for 80-plus years, providing a comprehensive national health delivery system designed to elevate the health status of American Indian and Alaska Native people to the highest possible level and to encourage the maximum participation of tribes in the planning and management of those services.
Although Native tribes are sovereign nations, the IHS is a U.S. government organization operating under the Department of Health and Human Services (HHS) umbrella. Today, it cares for 1.6 million of the nation’s estimated 2.6 million Native Americans from more than 560 federally recognized Indian tribes and Alaska Native corporations coast to coast.
The IHS is an extensive system, divided into 12 regional areas, that encompasses 36 hospitals, 63 health centers, 44 health stations and five residential treatment centers in 35 states. In addition to these facilities, most of which serve American Indians who live on or near reservations, the IHS also has 34 urban Indian health projects that provide a variety of services. Some IHS facilities are managed by the tribes themselves with financial and administrative support from the federal agency. At others, all daily operations are completely managed by IHS.
Nurses hired at tribally operated facilities (“direct hires”) are considered employees of the tribe. If the nurse is recruited by the IHS to work at a federally operated facility, then he or she is a federal employee. In addition, some nurses who work for the IHS do so as officers in the U.S. Public Health Service Commissioned Corps, a federal program under the direction of the U.S. Surgeon General in which nurses work for local, state, federal or international health agencies in a variety of capacities. Generally, nurses in the Commissioned Corps tend to have more experience and education and receive an expanded benefits package.
According to IHS statistics, there are currently more than 2,500 nurses in the organization working in inpatient, outpatient and ambulatory settings. Additionally, the agency employs public health nurses and nurse educators to carry out its numerous health awareness programs, among other duties. Many of these campaigns are created with input from tribal and spiritual leaders to address a particular community’s specific health care and cultural concerns.
Of course, like any large health care system, the Indian Health Service also provides opportunities for experienced clinicians to move into management positions on local, regional and national levels. But it’s the challenge of working with a unique patient population in a specialized environment that many IHS nurses cite as the most rewarding aspect of their career.
Like other health care employers today, the IHS is struggling under the weight of a severe nursing shortage and the increasing financial burdens of doing business in the current economic environment, despite a proposed budget of $2.9 billion for fiscal year 2004.
“We have a 14% nursing vacancy rate right now, compared with the national average of 13%,” says Celissa Stephens, RN, MSN, acting principal nurse consultant and senior recruiter for the IHS national headquarters in Rockville, Maryland.
The reasons for the nurse staffing crisis within the IHS mirror those for the health care industry in general. Fewer young people are choosing nursing as a career, while at the same time, the current RN population continues to inch toward retirement age. But this second factor has had an even bigger impact on the IHS than on private sector nursing employers. “The average age of nurses in the IHS is 48 years old, which is even older than the national average of 43 years,” Stephens explains.
More specifically, the IHS reports that approximately 755 of its 2,500 nurses are 41 years old or older. Of those, 8% were eligible for retirement last year. Even more alarming is that another 20% will be reaching retirement in the next five years.
While skilled, experienced nurses are urgently needed throughout the IHS system, Stephens says some specialties are in more demand than others. “At the present time, the greatest needs are in the areas of emergency, operating room, ICU and obstetrics,” she reports. “We’re also interested in Certified Registered Nurse Anesthetists (CRNAs).” There are also many career opportunities open for advanced practice nurses and Certified Nurse-Midwives.
“Everything you do [as an Indian nurse working for IHS], you can see it making a difference. You’re working toward a goal to improve the health of our families and communities,” says LaVerne Parker, RN, MS, an IHS nurse consultant in the Aberdeen Area of South Dakota and a member of the Turtle Mountain Band of Chippewa Indians.
Indeed, there seems to be a very strong connection between American Indian/Alaska Native nurses and careers in the IHS. The agency reports that approximately 66% of nurses working in the federal system or for tribally operated health care organizations are Native Americans. While this may be partially due to the fact that IHS has Congressional authority to give American Indians and Alaska Natives preference in hiring, working for the IHS also appears to be a traditional career path for many Indian nurses.
For instance, Parker grew up relying on the IHS as her own health care provider. When she became interested in a nursing career, IHS was foremost in her mind. “I always wanted to work with my own people,” she explains.
“There was never any doubt that I would be working for my [Indian] community,” says Lisa Sockabasin, RN, BSN, of her career choice as diabetes nurse coordinator for the North American Indian Center of Boston, an urban IHS facility in Boston, Massachusetts. “I saw so many health disparities among American Indian communities during my experience as a research fellow at Harvard Medical School, including cardiovascular disease, diabetes and cancer. I really wanted to work in preventing morbidity and mortality in our communities.”
While it may be a sense of community that brings Native nurses to IHS facilities, it’s the rewarding work and career advancement opportunities within the system that are keeping them there. Working for an IHS or tribal-run hospital or clinic is different than the “typical” nursing job in a number of ways. First and foremost, the patient population is almost exclusively American Indian or Alaska Native. Therefore, culture plays a very prominent role in health care delivery.
“There are so many different meanings of what good health is and how it’s perceived in so many different cultures,” says Sockabasin, who is half Patsanaquoddy Indian.
Culturally and linguistically, Indian tribes are by no means all alike, even though there may be some common threads among the different groups when it comes to health issues–such as high incidence rates of heart disease and diabetes–as well as general beliefs about health and illness, such as an emphasis on the use of natural remedies.
“You can’t make generalizations about the tribes because they’re all different,” emphasizes Stephens, a member of the Choctaw tribe. “It’s important at the local level that new employees are provided with culturally appropriate orientation to the tribal communities they will serve.”
Language can also impact health care delivery in Indian communities, especially with older patients who may not speak English very well or at all. The majority of IHS settings have an interpreter on staff, or other bilingual staff members who can help with translation. However, caution must be used in this circumstance, because when it comes to health care terms there is little room for misinterpretation.
“Some medical terms, such as cancer, don’t translate into the Navajo language, for example,” Stephens explains. “The term for cancer in Navajo could be described as ‘lood doo na dziiyigii,’ which means ‘a sore that does not heal.’
“Traditional Navajos believe that spoken words are like arrows, and arrows can wound people,” she adds. “Therefore, it would not be appropriate to discuss the patient’s mortality or potential outcomes in the first person. In order to avoid ‘inflicting wounds,’ the care provider must discuss the medical condition in the third person–for example, ‘some people experience x, y and z.’”
One of the most distinguishing features of a nursing career with the IHS is where you work. The vast majority of IHS hospitals and clinics are set on or near Indian reservations, which are usually in rural areas. Not only are they small communities, but they’re often located at substantial distances from the nearest town or city, which can be problematic for nurses who have families or are not accustomed to small-town life. For example, there may not be immediate access to employment and social outlets for spouses and children.
“Families have to adopt a certain lifestyle to live in our communities,” notes Stephens. “We need nurses who have a sense of adventure, are willing to accept the challenges of a rural lifestyle and are interested in being involved in the communities they serve. On the other hand, IHS nurses get to experience the [richness of] Native community life and culture. You may not get that opportunity in the private sector.”
Indeed, when HHS Secretary Tommy G. Thompson announced the awarding of $1.7 million in grants to six American Indian and Alaska Native tribes and organizations last fall to assist them in recruiting and retaining health care professionals, he specifically cited location as a contributing factor to the ongoing need for health care personnel. “The national shortages of nurses, physicians, pharmacists and many other health professionals is particularly serious in the remote and isolated areas where many tribal communities are located,” Thompson noted.
The HHS grant recipients were the Maniilaq Association in Alaska ($99,931), the Ketchikan Indian Corporation in Alaska (($91,693), the Seneca Nation of New York ($96,467), the Nisqually Indian Tribe in Washington state ($100,000), the Confederated Tribes and Bands of the Yakima Nation in Washington ($100,000) and the Northwest Portland Area Indian Health Board in Oregon ($92,209).
Like other health care employers that urgently need more nurses, the IHS is intensifying its recruitment and retention efforts, both within and outside the American Indian and Alaska Native communities it serves.
“Having Native American nurses in the community is probably our biggest retention key,” says Parker. “Many of them have been able to go to nursing school through IHS scholarships and they come back here [to work] and they stay. They are our staple staff.”
Of course, another key to attracting and retaining nursing talent is to offer plenty of professional development opportunities. And the IHS certainly has its share. For example, new RN graduates can compete for a position in the RN Internship Program, which allows them to rotate through a variety of different nursing specialties in a preceptor-like training environment.
Another option is the Public Health Nurse Internship, where nurses with BSN degrees receive specialized training as health educators and advocators. For nurses with at least one year of clinical experience, the IHS offers residency programs in critical care, OR and obstetrics, often with the opportunity to become certified upon completion.
To participate in any of these programs, however, nurses must be willing to move around, because they are only offered at specific IHS facilities. “We have the most difficulty recruiting in obstetrics or the OR because there are so few IHS hospitals in our area that offer those training programs,” states Parker. “We’re trying to develop more programs locally, but for now, we also work with outside hospitals that might provide our nurses with training services.”
Then there are long-term training and continuing education opportunities that help nurses at various career levels pursue academic degrees. For example, American Indian and Alaska Native nurses employed with IHS, tribal or urban facilities can take advantage of long-term training opportunities such as the Section 118 program. In this program, which is sponsored by the IHS Headquarters Division of Nursing, LPNs can pursue either an associate’s or bachelor’s degree in nursing; RNs with associate’s degrees can pursue BSN degrees.
“To date, more than 55 nurses have received advanced training and additional degrees through IHS long-term training programs,” says Stephens. “Currently we have 18 nurses in advanced training. Nurses receive full salary, benefits, books and tuition while pursuing advanced education. That’s a benefit the private sector usually does not offer.”
In addition, financial aid opportunities for third- and fourth-year student nurses are available through COSTEP, the U.S. Public Health Service’s Commissioned Officer Student Training and Extern Program.
But perhaps the single most irresistible benefit for nurses is the IHS Loan Repayment Program. Simply put, this program offers nurses–including tribal direct hires–repayment of up to $20,000 per year toward nursing education loans. In return, the nurses agree to a minimum two-year service contract at an IHS facility, usually one that has a high nursing vacancy rate.
Being an Indian Health Service nurse is an opportunity for minority nurses of all races and ethnicities to live a unique personal and professional experience that is simply not available anywhere else. Not only will you encounter a fascinating culture and people, but your expertise as a nurse will be valued and broadened. Within a health care system that offers such a broad spectrum of services, the opportunities to explore different career specialties and gain additional skills are wide open.
“When I worked in the private sector, I didn’t have the ability to move from clinics to ambulatory to inpatient or emergency,” says Parker. “But within the IHS, you can work in a variety of areas and with a variety of cultures.”
You’ll also see how your efforts to care for, educate and advocate for patients can have a ripple effect on the entire community. As Sockabasin explains, “When you work for the IHS, you have the ability to touch a population that is in so much need of good nurses.”
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