For Native American nurses, many of their stories have been lost to the past. Scholars have generally paid scant attention to the lives and deeds of rural minority women, and few articles have been written about the early education of Native American nurses and their contributions to health care. The people of the Catawba Indian Nation use storytelling to keep their culture and the memory of their heroes alive. Consider this one such story, one such hero.
The Sage Memorial Hospital School of Nursing, known simply as “Sage Memorial,” operated from 1930–1953. It was the only nursing school ever opened for the sole purpose of educating Native American women as nurses.1 One of these nurses was Viola Elizabeth Garcia, a graduate of the Class of 1943.2 Viola’s life illuminates the struggles for education common among the women who attended Sage Memorial. Her contributions and experiences as a World War II nurse demonstrate the hardships encountered and outstanding contributions made by many of her fellow alumna.
By law and custom, most nursing schools were segregated by race before the passing of the Civil Rights laws of the 1960s. From the 1880s through the 1960s, most schools of nursing were comprised of either all white or all African American student bodies, leaving few opportunities for Native Americans, Asian Americans, or Hispanic Americans to obtain a nursing education.
The Board of National Missions of the Presbyterian Church was unique in its efforts to address this inequality. In 1901, the National Presbyterian Church opened the Ganado Mission on Navajo Nation land, in the northeast quadrant of Arizona, near the New Mexico, Colorado, and Utah borders, in the community of Ganado.
After a church and school were successfully operating at the Mission, the home missionaries turned their attention to health care.3 In 1929, Dr. Clarence Salsbury and his wife, Nurse Cora Salsbury, took over the mission work at Ganado. One of their first priorities was expanding the antiquated 12-bed hospital into a modern facility of 150 beds, an operating suite, a delivery suite, and a laboratory. This new hospital was named Sage Memorial Hospital after one of its largest benefactors and was accredited by the American College of Surgeons.
In order to staff the hospital with nurses, as well as to provide skilled employment opportunities for Native American women, the Salsburys opened Sage Memorial Hospital School of Nursing in 1930.4
The school opened while naysayers proclaimed no Native American woman would ever be up to the academic task of completing a Nightingale-based nursing education program. They also claimed these women, given their culture, would not be willing to interact with the sick or dying. Sage Memorial graduates proved these assumptions wrong.
Dr. Salsbury felt training Native American nurses was crucial. “They would be able to understand the patients as no white personnel ever could,” he said.1 Sage Memorial started small, with an entering class of two Navajo women: Adele Slivers and Ruth Henderson. They both graduated three years later and passed the Arizona State Board of Nursing Examinations. Their graduation exercises in 1933 were a festive event with scripture readings, vocal duets, a piano solo, and a pinning ceremony. Dignitaries including the Arizona governor, an Arizona State Board of Nursing member, and one of the chief Navajo medicine men praised the graduates and the school during the proceedings.3
As word and reputation of the school expanded among minority communities, the student body increased in number and diversity. By 1943, students from 28 tribes, including the Navajo, Kiowa, and Catawba; students who identified as Eskimo, Hawaiian, Spanish American, Cuban, and Mexican; and one Japanese student from a relocation camp were either enrolled or graduates of Sage Memorial.6 By all accounts, this unique experiment in multicultural education was a success.
In the 1930s and 1940s, such training and cultural exchange among Native Americans and other minority women was not found anywhere else in the United States. The nurses developed a camaraderie and commitment to their work that consistently earned them the highest marks on state licensing exams. The students lived in interracial cooperation while learning the nursing arts and sciences. The school’s stellar reputation drew the attention of white applicants—who were denied consideration because they had access to many other schools of nursing.1
Viola Elizabeth Garcia
Viola Elizabeth Garcia was born on April 12, 1919, in Sanford, Colorado, a poor, rural Mormon community home to approximately half the members of the Catawba Nation. Viola’s family was financially impoverished, but rich in family and culture. The older brothers, George and Labon, left school after completing the fourth and fifth grade to help their ailing father support the large family. Viola’s father was ill for much of her young life and died when Viola was only 11 years old, leaving behind 10 children for his wife to support.
Viola completed the ninth grade in Sanford, but due to the Great Depression, the public high school was closed. For the next three years, Viola tried desperately to complete her high school education by repeatedly applying for admission to the Bureau of Indian Affairs Haskell Boarding School in Lawrence, Kansas. Finally, she was admitted at 18 years old and completed her high school diploma in 1940 at the age of 21. Viola’s classes focused on cooking skills, sewing, home care, and arts. As graduation neared, she was offered full-time employment as a cook’s assistant on the Apache reservation in New Mexico, but Viola was determined to continue her education.2
With the guidance of the staff at Haskell Boarding School, Viola applied to several nursing programs but was only admitted to Sage Memorial. One such rejection stated that she was too old at 21 years of age to begin the nursing program. There was also a concern, as World War II loomed and U.S.-Japan relations became strained, that her Native American features would appear Japanese and frighten patients.6
The head mistress of Haskell wrote in a reference letter about Viola, “Whatever Viola decides to do, she does.” Several months after Viola enrolled at Sage Memorial, Dr. Salsbury personally wrote the Haskell headmistress asking if she had any other students like Viola, and if so, to please send them to his school.6
Studying at Sage Memorial
Applicants to Sage Memorial had to be unmarried high school graduates between 18–30 years of age. Their applications had to be accompanied by a health certificate, as well as four character references, with one being their pastor. Tuition was $100 for the first year with additional fees of $1 for laboratory courses, $0.50 for library use, and $3.50 for health fees. The hospital provided room, board, and laundry services. In addition to their course work, students tended the hospital floors eight hours a day, six days a week. However, students had time to relax outside of their rigorous classroom and clinical schedules, enjoying picnics, parties, movies, and glee club, as well as mandatory gym class and chapel.4
Although Viola was accepted to Sage Memorial, she was not sure that she could afford the tuition, fees, and living expenses. As the months progressed, Dr. Salsbury procured the funds to pay for all her education expenses except for personal items she needed to bring with her.6 According the 1940 catalog, all students had to supply for themselves the following: a bag for soiled clothing, rubbers or galoshes, toiletries, two fountain pens (one for red ink and one for blue), a watch with a second hand, an alarm clock, two standard-size loose-leaf notebooks, a napkin ring, and coat hangers.4 Viola’s eldest brother, George, gave her an entire month’s wages so she could buy the required watch with the second hand sweep. With her determination and supplies in tow, Viola began her three-year long education at Sage Memorial.6
Over the next three years, Viola and her fellow students not only studied the nursing curriculum but also spent many clinical hours on the hospital floors. They made and rolled their own patient bandages and folded disposable patient trash bags and slippers out of newspapers. Third-year students were expected to help teach the lower-level nursing students. Viola not only learned the nursing skills that she would use throughout her life, but she developed a deep devotion and admiration for the Navajo people. She even taught herself to speak Dine, the Navajo language.6
A nurse in practice
Though Viola grew up in the rural, remote, and poor town of Sanford, she was surprised to learn that her new community at Ganado was even more so. Patients were brought to the hospital on horseback and buckboard wagons, and sometimes by rattling old vehicles over rutted and narrow dirt roads. Many roads were so rough and rocky that they were impassable in wet and winter weather. The nursing students were expected to go on home visits with the nursing staff to the homes of the Navajo people, traditional dwellings known as hogans.7 They made these visits in buckboard wagons. Viola would write back to her mentor at Haskell Board School that these hogans were “loving and cozy homes.”6
Viola viewed success as the ability to provide for herself, and she felt her education was essential to achieving that level of self-reliance. Viola studied hard and was the 1943 class valedictorian. She was awarded a set of surgical instruments for her academic success.
In 1943 Viola took her Arizona nursing boards and returned home to Colorado to await the results. She had been worried because she did not have an additional $75 to retake the nursing board examination if she failed. One day a letter arrived addressed to Viola Garcia, R.N., and she knew she had passed. In fact, Viola received the highest test score in the entire state of Arizona. Viola’s academic and nursing success, however, was common among the students who graduated from Sage Memorial.
World War II
Not long after graduating from nursing school, Viola found herself working in Denver, Colorado, when President Roosevelt delivered an ominous speech. While the war efforts in Europe were drawing to a close, battles were still raging in the Pacific, and there might be a need to draft nurses into the military. Viola was told that if she volunteered for military service, she could select her location of duties. In January 1944, she enlisted in the United States Army Nurse Corps, requesting no surgical duties or overseas assignments. Within weeks of her enlistment, she was assigned to Camp Carson (now, Fort Carson, Colorado Springs, Colorado) in the surgical suite where she assisted with amputations from the war-wounded returning from the bitter winter campaign in Europe under General Patton. There were endless mounds of amputated ears, fingers, toes, hands, feet, arms, and legs that filled the air with putrid smells. Viola approached her supervisor and informed her of what she had requested: “No surgery and no overseas duties.” She was promptly informed, “Honey, you are in the Army now.”6
Within a few months, First Lt. Viola Garcia shipped out from Camp Carson to Los Angeles, where she, along with 600 other nurses, embarked on the largest U.S. Army Hospital Ship at the time, the USAHS Marigold, with an unknown destination. After two weeks, the ship arrived in Hawaii, and 300 of the 600 nurses disembarked, but Viola’s group remained on board. After leaving Hawaii, ship’s public address system announced their destination: Tokyo, still a heavy battle area as the war in the Pacific raged on. “My heart just dropped, I was so frightened,” Viola recalled. The U.S. military was fighting Japanese troops on many Pacific Islands and an invasion of the Japanese mainland was thought to be imminent. The costs in human life for both sides would be high.6
The ship was under the command of General Douglas McArthur, who over saw the military operations in the Pacific. The 300 nurses in Viola’s grouping were to be part of the U.S. invasion actions in Japan. Military leaders expected heavy casualties among those nurses during the invasion operations; the 300 nurses left behind in Hawaii would be their replacements.
Under international rules of combat, hospital ships were not to be attacked at sea, and thus were to be lit up at night and clearly marked with a red cross. Not long out at sea, the Japanese attacked one such marked ship, and the Marigold was immediately ordered to go into complete darkness. As the lights were put out, those in surgery raced to cover the windows of surgeries in progress. A frightening silence fell upon the crew as the Marigold steamed along in darkness on its way across the Pacific.
The Marigold stopped in the Philippines, and the nurses were allowed to disembark for a few days before the ship went to Japan. While docked there, however, the United States dropped the atomic bombs on Japan, and World War II was brought to a close. Yet, the Marigold continued on to Tokyo, but this time with a different mission. The USAHS Marigold was the first U.S. ship to enter Yokahoma Bay after the Japanese ended the war, and it was in Tokyo Bay where General McArthur accepted the formal surrender of the Japanese on the USS Missouri. That day the sea was filled with ships and the air was filled with flyover planes celebrating the end of the Second World War.
Rebuilding in Tokyo
Over the next eight months, Viola was stationed in Tokyo at the 42nd General Hospital. She treated survivors of the Bataan Death Camp and Corregidor Island (a military stronghold in the Philippines). The hospital had five surgical rooms that had been stripped of all equipment by the Japanese at the end of the war. They were filled with soot and rubble. Several Army nurses ranking higher than Viola were assigned the task of restoring these rooms to their full function. According to Viola, none of the higher-ranking nurses could deal with such an overwhelming task; each time, Viola was asked to “fill in.” After a third nurse was left in tears at the monumental task, Viola was asked to take on the responsibilities as acting head surgical nurse.6
Viola walked into surgical suites devoid of the equipment necessary for performing operations—no surgical tables, no IV stands, no surgical tools. She remembered entering the rooms: “I just wanted to cry too and said to myself, ‘Oh Lordy, what am I going to do?'” But Viola went on to do what she had always done—she rolled up her sleeves and got to work. Viola called in her military crew and ordered them to wash and scrub all the rooms from top to bottom. When that was done, she began looking for equipment for her surgical rooms, including salvaging items from the hospital ship.6 She even taught herself to speak Japanese, just as she learned to speak Dine as a nursing student.
First Lt. Garcia’s work in Tokyo was supported by her own ethic of care, as well as the training she received at Sage Memorial Hospital School of Nursing. From those days following the war until her death in 2004, Viola continued caring for others, marrying Herbert Schneider, another member of the U.S. Army, and raising three daughters. Her legacy, one of determination and pride, compassion and grace, lives on.
- Salsbury, C.G., & Hughes, P. (1969) The Salsbury Story. Tucson: The University of Arizona Press. 152–153.
- People of Catawba official website, “Life of Viola Schneider.” Cynthia Walsh. http://www.catawba-people.com/viola_schneider_eulogy.htm. (Accessed 2011).
- Trennart, R. (2003). “Sage Memorial Hospital and the Nation’s First All-Indian School of Nursing.” The Journal of Arizona History, vol. 44, 353.
- Prospectus of School of Nursing, (Ganado, Arizona: Sage Memorial Hospital, n.d), 1-11; Presbyterian Historical Society, Philadelphia, Pennsylvania: Ganado Mission Records.
- “Excerpts from Statement re: School of Nursing, Sage Memorial Hospital, Ganado, Arizona sent in on January 3, 1939.” Document from Ganado Mission Records, Presbyterian Historical Society; Philadelphia, Pennsylvania.
- Viola Garcia, personal comm. with author.
- Salsbury, C.G. (1932). “Medical Work in Navajoland.” The American Journal of Nursing, 32(4), 415.
Spring is the season of new life, even rebirth. It’s a fitting time for graduation ceremonies to be held, as young professionals embark on new careers that had previously been half-lived in textbooks and lectures.
Soon, thousands of members of the Class of 2012 will be flooding into the “real world” to join the team on hospital floors, in emergency clinics, and at countless other nursing facilities. Here, you’ll meet four soon-to-be members of the nursing work force, as they share the experiences that led them to their field, their hard-won advice for future students, and what they believe will keep them in nursing for the long haul.
Breanne Cisneros, R.N.
“People like you don’t go to schools like these.” That’s what Breanne Cisneros heard when she showed someone the list of colleges and universities to which she hoped to apply. “I was shocked,” Cisneros says. “Even though I was a low-income, Hispanic American female who had attended impacted public schools in the under-served city of Anaheim, California, I applied to top-tier institutions.” She eventually was offered admission and a full scholarship to Johns Hopkins University in Baltimore, Maryland.
Now, Cisneros is in the Master’s Entry Program in Nursing (MEPN) at the University of California, San Francisco (UCSF). She became an RN in 2010, and she is pursuing a master’s in critical care/trauma nursing. She hopes to become a critical care clinical nurse specialist. Cisneros says she “dreamed of working in health care” as a child, largely due to growing up with a disabled younger brother.
At Johns Hopkins, studying psychology, Cisneros says she “quickly learned [that person] was right—people like me don’t go to schools like that. Having come from a completely different socioeconomic background than my peers, and having very few shared experiences, I was isolated.” Not only that, she found her ambitions shaken during her academically challenging undergraduate years. “I lost faith in my abilities, and temporarily gave up on my dream,” she says. But her school and life focus shifted during her junior year at Hopkins, when her father sustained a traumatic brain injury (TBI) due to violent crime that left him permanently disabled. “This multifaceted tragedy changed my outlook and approach to life, resulting in a shift of priorities. It renewed my dedication to health care and motivated me to reach out to gain the academic skills I needed for success,” she says. “The RNs and Advanced Practiced Nurses provided warm, competent, patient-centered care that allowed my father and our family to heal. It opened my eyes to the world of nursing and changed my career and life trajectories.”
As a social work assistant in oncology at the Johns Hopkins Hospital and as an EMT-B in Baltimore, Cisneros “saw great socioeconomic disparities and their impact on health and access to care,” she says. “I recognized that my background was a unique tool that would allow me to help people who are scared, do not have adequate resources, feel isolated, and who do not understand the health care system or what is happening to their bodies. The Hispanic population is particularly vulnerable and subject to trauma, which I experienced firsthand.”
After graduating, Cisneros fulfilled her nursing prerequisites in a post-baccalaureate program at Tufts University in Medford, Massachusetts. “My educational journey has been just that: a journey,” she says. “I have struggled and faced many obstacles because of my background and socioeconomic status. However, support from the National Association of Hispanic Nurses, the Kaiser Permanente Latino Association, the Hispanic Association of Colleges and Universities, and the UCSF Nursing Alumni Association has helped me tremendously in achieving my goals and working towards my dreams.”
As an undergrad at the famously “physician-dominated” Johns Hopkins, Cisneros says she developed a “passion for interprofessional health care education.” She was the first nursing student to receive a fellowship to participate in the UCSF School of Medicine’s Curriculum Ambassador’s program, and she was the only nurse on the six-member team of interprofessional students. Together they developed and facilitated a nationally recognized, “revolutionary, school-wide, student-driven, student-centered interprofessional health care education curriculum for 500 students across the five health professions programs at UCSF,” she says. “Increased patient safety requires interprofessional collaboration, which is now critical given rising health care costs, an aging population, and physician shortages.” Cisneros and her team will continue to study the impact of interprofessional learning on collaboration, she says. She applies the skills developed in this program as a student representative on the Interprofessional Healthcare Education Task Force at UCSF as well, where she works with deans and other faculty members.
Among her other extracurricular activities, Cisneros is one of five MEPN students serving a fellowship as a Clinical Scholar at the UCSF Medical Center, where she contributes to the Medication Administration Accuracy Project (MAAP) in Nursing Performance Improvement. “The goals of the MAAP project are to standardize the medication administration process and eliminate nursing medication errors,” Cisneros says. “The vision is to establish best practices so that every patient receives safe, excellent quality care.” This experience led Cisneros to becoming the first nurse to complete a School of Medicine Pathway to Discovery certificate in Health Systems and Leadership, a career development program with a leadership focus.
After committing herself to these organizations, it’s no surprise Cisneros is passionate about leadership. Her most recent leading role? Studying the 24-hour survival rates for VT/VF (Ventricular Tachycardia/Ventricular Fibrillation) arrest at the San Francisco Department of Veterans Affairs, working on a quality improvement project studying early chest compressions and defibrillation within two minutes of cardiac arrest. “The best strategies are unclear for hospital implementation of early defibrillation programs,” she says. “In-hospital cardiac arrest is a major public health issue, and both the American Heart Association and the American College of Cardiology recognize the importance of early resuscitative care.” Cisneros and her team explored the feasibility of a two-minute defibrillation standard for monitored units to identify best practices as well as barriers to successful early defibrillation in cardiac arrest, among other things. The American Heart Association published the abstract and accepted it for their 2011 national meeting; Cisneros went there to present those findings. “This was an incredible opportunity to conduct scholarly work and present it at a national level,” she says.
Cisneros shows no signs of slowing down. And after the challenges of her not-so-distant youth, she intends to give back to those facing similar difficulties. “I plan to be a role model and make changes to the system that will help recruit, retain, and to encourage further professional and academic development of underserved students like myself,” she says. “My contributions towards the well-being of individuals are limited unless I can pass my knowledge onto others.” To that end, she hopes to earn her Ph.D. in nursing, and she is already an early advocate for the degree. “A Ph.D. is invaluable for improving patient care, contributing to research, informing health policy, improving the nursing practice, and developing the profession,” Cisneros says. “As a Hispanic nurse, I would add to faculty diversity and help to create a healthy culture in the learning environment.” However, Cisneros says those days are still far away; she intends to develop her skills at the bedside first and let that knowledge inform her doctoral studies.
“Through advocacy, outreach, and strong professional organizational involvement, I plan to actively make changes and reach out to Hispanic nurses—to recruit them, to retain them, and to encourage further professional and academic development,” Cisneros says. “I feel a responsibility to communicate my future clinical, educational, and research findings to my colleagues. As a nurse, I not only plan to meet the needs of my patients, but also meet the needs of my colleagues, Hispanic nurses. I believe that we must be involved in nursing at the local, state, and national levels in order to impact health policy and improve health care for Hispanics, and gain visibility and recognition as professionals so that we can influence and facilitate such change.”
Even as a child in Nigeria, Musiliu Ogunbayo was acutely aware of the importance of health care and wellness. He applied that interest to the study of nursing, and he should graduate from the practical nursing program at The Salter School of Nursing and Allied Health in Manchester, New Hampshire, this spring. (He hopes to earn a bachelor’s degree in the future.) Ogunbayo’s career path was perhaps made more profound from early experiences with the tribal custom of tattooing.
“I am always proud of my cultural heritage,” Ogunbayo says. “We, the Yorubas, are known all over Nigeria and, indeed, the whole world for our tribal marks.” However, he did not receive the customary tattoos as an infant, due to his father’s absence at the time. After being ridiculed for his lack of tribal marks as a child, Ogunbayo finally, excitedly, went to have them done at the age of nine. This decision was also heavily influenced by his admiration of his school teacher and his tribal marks.
The tattoo incisions were made by a local baba, an elderly manwith experience administering the tattoos, using an old, rusty blade. Ogunbayo found himself in great pain following the procedure and for several days afterward, and he questioned his decision to have them done.
Upon returning to school, his teacher commented on the new tribal marks; Ogunbayo shared how the teacher himself had actually influenced his decision. The teacher’s surprising reply: he hated his own tribal marks. Having been done as an infant, he had no choice in the matter and now had to live with them. This led Ogunbayo to consider his own tattoos, and he pondered the health risk he had taken just in having them done. “Sometimes, I sit and think, ‘what if the baba had used that knife on someone with HIV before using it on me?’ I also imagine what if bacteria from the knife or from the [dye] had entered my bloodstream, causing an ailment that could not be cured?”
After graduating, Ogunbayo intends to work in America to gain more experience, which he will then take back to Nigeria. “I feel like a lot has been given to me, so I chose nursing as a career because I want to be able to give back to my community someday,” Ogunbayo says, and he hopes to apply his nursing knowledge and create more awareness upon returning home. “I want to be able to contribute to a healthier environment where people are more cognitively aware of their health needs. I want to see a society where people would not have to wait till they get very sick before they go to see the doctor. I want to help build a society where people with medical needs are treated with fairness and respect.” He intends to open a clinic in his home country to provide high-quality, affordable health care.
To would-be nursing students, Ogunbayo does not shy away from the difficulties of the program: Cutting down on his work hours to make time to study has also cut into his income, causing a strain in finances. Socially, he has little time for friends or family. “The biggest of all is a cultural conflict,” Ogunbayo says. “I always find myself having to do something different from the way I was raised. But I finally understand that meeting my patients’ cultural and health needs is more important.”
And Ogunbayo sometimes finds being the only male in his class to be a challenge, but he credits his instructors and classmates for giving him a positive learning experience. “Make sure you choose a good school that meets your career goals, financial status, and lifestyle,” Ogunbayo says. And don’t forget: “Your instructors are your best resources; use them and see them as your mentor and not your judge.”
Despite its challenges, Ogunbayo maintains his passion for the field. “Nursing is a very rewarding profession,” Ogunbayo says. Even if the particular field or specialty a nurse pursues isn’t the most lucrative, such as treating impoverished peoples, “you will be happy for the differences you are making in people’s lives.”
Kelsey Sonnabend finds strength and meaning all in one quote: “To the world you may be one person, but to one person you may be the world.” She adopted this saying from her friend Kate, and she relies on it when her work and studies in Arizona State University’s (ASU) B.S.N. program become challenging. “This quote is what makes it all worth while in the end,” she says. “That one patient that you help that looks you in the eye and tells you how thankful they are that you are there helping them when they can not help themselves.”
A native of Gilbert, Arizona, Sonnabend’s family is from Rapid City, South Dakota. They are members of the Oglala Sioux tribe situated on the Pine Ridge Reservation, roughly 120 miles away. “I was raised so far from my reservation because my dad is a part of the commissioned corps and was placed in Phoenix, Arizona, to work,” Sonnabend says. “However, I remember spending my summers in South Dakota visiting my family and grandpa, Pahaska who, if you have ever been to Keystone, South Dakota, is the amazing Native American painter who many tourists took pictures with.”
Sonnabend is currently in her final semester at ASU, scheduled to graduate in May of this year. As a high school student, she says she couldn’t decide what to study in college—but she did know she wanted to impact others in her work. “I knew there was many different ways I could do this, either through politics or business,” she says. “Then I remembered my mom.” Also a nurse, her mother would share work stories with Sonnabend and her brother. “I remember listening to her stories and how much people appreciated what she would do for them.”
But as the years went by, different factors colored Sonnabend’s desire to become a nurse. The first was her determination to prove naysayers wrong. Second in time, but perhaps more importantly, Sonnabend became friends with a fellow nursing student, the aforementioned Kate. “We took many classes together and went through many grueling nights of studying, editing each other’s papers, and the stress of applying for the program together,” she says. In the spring of 2009, Kate grew ill, her health declining quickly and impacting her school work.
“Kate had many strange symptoms of many things and saw many doctors,” Sonnabend says. “When the semester ended I remember eating a grilled cheese sandwich with her and her telling me a doctor told her it was a severe sinus infection and she was headed home to Washington to get it all fixed up and she would see me in the fall for our first semester of nursing school. Two days later I got a call that she had passed away. That completely changed my world. Everything was different; to truly see how fragile life is was so shocking for me. I then at that point made the decision that no one should have to go from doctor to doctor in pain and fear. I wanted to be that nurse who would be more caring, loving, and support my patients.” Talking with Katie’s parents after her passing only solidified Sonnabend’s resolve. “What initially inspired me to be a nurse was the amazing, caring, and courageous stories of my mom,” she says. “What changed the kind of nurse I would be and re-kindled the want to be a nurse was the death and life of my friend Kate.”
Sonnabend hopes to use her nursing degree wherever she is needed, she says, whether that’s a well-known hospital in Phoenix, a third-world country, or another underserved area. She also wants to earn her master’s and doctoral degrees to further her abilities to help those in need.
“Walking into this program, there are a lot of stresses, such as the need to have a high GPA, competing against many other highly qualified students, and spending four years of your life strictly focused on studying and school,” Sonnabend says. She remembers being warned during the first week of school: even if you get into the “impossible” nursing program, you probably won’t graduate on time. Right on schedule, four years later, Sonnabend is ready to enter the nursing workforce.
Though she admits she found her studies challenging—“it does take a lot of self-discipline and sacrifice,” she says—in Sonnabend’s young life, she has found this much to be true: when you’re passionate and committed to becoming a nurse, nothing can stop you. Even those that might falter along the way can push themselves to achieve their goals. To the generations of nurses to come after her, she has this to say: “You have the ability to do anything another human has done.” Even if you sometimes struggle academically, “this simply means you just have to put a little more time in figuring out the way you learn best,” she continues. “Do not listen to everyone around telling you that you aren’t smart enough or that nursing is not a good field, because if this is what you want you shouldn’t let those things get to you. If you work hard and you keep in contact with your school advisors and professors, you will get far. It is a difficult program but it really will be worth it when you finally get to walk across that stage and call yourself an RN.”
David Allen didn’t always want to be a nurse. He did know, however, that he had a passion for medicine in a broad sort of way. Growing up in the Boston suburb of Natick, Allen was a “pretty big athlete,” and he developed an interest in muscles, body movement, and his own physical therapy and sports-related injuries. Allen says he spent a good deal of time in the ER and even negotiated with his orthopedic doctors. He’ll be graduating in May of this year with a B.S.N. from the University of Pennsylvania School of Nursing.
“I’ve always been really interested in emergency medicine,” Allen says. At 16 years old, he wanted to be an EMT. He took a wilderness first responder exam to get involved in outdoor recreation, and his adventurous spirit endures. “My dream job would be a flight nurse, which I know isn’t that original for a guy!” he says with a laugh.
The decision to study nursing came after the decision to attend UPenn, as the school simply “grabbed” Allen and met his overarching undergrad goals. A brief informational meeting with UPenn’s admission office introduced him to nursing, particularly the role of nurse practitioner, which he says he had never really heard of. It too clicked with him, as he realized it would allow him to do all the things that interested him.
Allen says it took a few years for him to really appreciate nursing and the ability to work one-on-one with patients. Now, he says he can fully articulate why he is happy with his choice to become a nurse.
Allen says his classmates are brilliant and highly motivated. “Everyone’s working to be the top in what they’re doing.” Yet, though his nursing class only started with about 10 males, several have dropped out, as did a number of nursing students in general. Given the trying nature of the first years of the nursing program, this didn’t surprise him. “It can feel subservient, especially in some of the basic classes,” he says. “You grow to appreciate the role nurses play in patient care—which is why we’re all here.” Allen says he believes the work will become more fluid, second nature, and perhaps easier as years go on and he gains more experience. “I think I’ve been really lucky,” Allen says. “UPenn does a really great job in supporting students.”
True to his past and his flight nurse dreams of the future, Allen says he enjoys the fast-paced nature of the emergency department, and he hopes to work in a similar trauma-based environment.
The challenges may scare would-be nurses, particularly those graduating from high school in this economically uncertain time, a world where nurses are desperately needed to fill current and projected future vacancies. But Allen offers some sage advice: “Really think about what you value and what you want to do, and then talk to people in other fields” to see if your vision of the future and the reality align, he says.
After enrolling in the program, know that it will be difficult. If you find you don’t love nursing, Allen says, give it a chance, talk to more people, and try to determine if what you don’t like is really indicative of nursing or if it might change as time goes by. Perhaps then you, like Allen, will find the rewards far outweigh the challenges.
Entering the patient’s room, I immediately took note of the look on the elderly woman’s face. There was no way I could look past her grimacing. As an African-American male nurse, I had seen this look before and knew it was in response to my gender, my race or both. Pulling away from the side of the bed where I was standing, she demanded: “Where are all the white people?”
Busy and rushed for time as most nurses are, I was not sure how to handle this situation and still get my medication pass done in a timely manner. I did not think therapeutic communication or touch would work in this particular case. She would not let me get that close to her, either physically or emotionally. Acting as if I could not comprehend her, I offered her the medications that were ordered. She looked at the medicine cup and abruptly said, “I’m not going to take that!” Now the dilemma had evolved into how to distribute medication to this patient.
Who knows what was going through this woman’s mind? Maybe she thought that my being alone with her in her room was a perfect opportunity for racial retaliation: Here was this black man who was finally going to pay her back for centuries of racial injustices. More than likely, she felt I was not intelligent enough to follow the physician’s orders and that the meds I was offering her were incorrect. At this point, it was all irrelevant. My intention was to help her, but in her mind I only represented someone from a race she considered inferior and had spent a lifetime hating.
This patient may not have known the date, or what the name of the health care facility was, or even her own name, but she could and did hold on to racial intolerance. Years of other life training may have abandoned her, but the training she had received about race remained intact. I saw in her face what could only be described as a mixture of hate, fear and anxiety. The year was 2004, but in my mind this incident transported me back to our nation’s past and gave me a taste of how ugly and complicated life must have been for past generations of black and white Americans.
Frustrated with my inability to administer medications to this patient, I exited her room and searched for the other nurse on duty. She was also African American, but I thought there was a chance she would fare better because she was female. This nurse was not new to the ward and she was not surprised by the patient’s reaction to me. When I asked her how I should handle this matter, she replied, “She won’t take medications from me either.”
Needless to say, this patient did not receive her medication that particular shift. I documented the incident and continued to care for the patients who would allow me to.
Unfortunately, it seems the only repercussions that resulted from this incident of racism were the painful feelings that have continued to stay with me. Nothing was ever addressed on any other level that I was made aware of. My employer’s apparent reluctance to acknowledge the problem disappointed me. It seems that even the most liberal and up-to-date facilities fall short when it comes to addressing this issue.
“Get Over It”
Another of my notable experiences involving racism in a patient care situation was an encounter I had with a veteran. This incident affected me deeply for two reasons. First, I am a veteran myself, having served eight years in the U.S. Air Force. Veterans usually feel a kinship toward other vets, regardless of their background, branch of service or duration of service. Secondly, I had taken care of this particular patient for some time and thought that our relationship had somehow transcended race. Until this incident occurred, our interactions had always been very cordial and respectful.
This was a patient who needed total care. He was paralyzed on his left side from a stroke and needed another’s help for even his most basic needs. The incident occurred on evening shift. Because of our limited staffing, once the total care patients were put to bed for the night it was our practice to leave them in the bed until morning. But on evenings when bingo was being played, I would help this patient get dressed again, put him in a wheelchair and push him to wherever the game was located.
He was prone to fits of yelling and anger, but in the past I had always been able to calm him down. Entering the room this particular night, I could tell that he was not in the best of moods, but I was not expecting the encounter that ensued. All of my attempts to calm him failed. In fact, they seemed to just heighten his anger. And at the apex of his anger, he yelled, “N- – – – -, get out of my room!”
Many emotions ran through me at that moment-certainly too many to count. What I did next escapes me. I assume I must have straightened his blankets and did what I thought would make him comfortable. I do know that I exited his room angry and told the charge nurse about the encounter.
The nurse in charge was totally sympathetic but at a total loss as to how she should handle the situation. I was sitting in the staff break room obviously angry and frustrated, with my arms crossed on top of my chest. She under- stood that she could not just let this incident go without some intervention on her part. Her decision was to call the house supervisor.
I had what I thought was a decent working relationship with the house supervisor, so I was not against discussing this incident with her. When the evening supervisor arrived on the ward, I was still in the break room fuming from the incident. She came in and asked me to explain what had happened; I gave her my interpretation of the incident. Her reply did nothing to soothe my anger. She basically said, “Get over it.”
She then began to relate some incidents of disrespect she had encountered in her own journey through nursing. Being called out of her name, having her level of intelligence questioned and being touched inappropriately were all situations she described. She seemed to indicate that this was part of our job and we had to take it.
I sat there listening, refusing to believe what I was hearing. I also refused to accept her personal doctrine that this type of treatment was “normal” and that nurses should accept it. I sat there respectfully, but her words did nothing to redeem my dignity or help repair my relationship with this patient.
The incident did send some minor ripples toward the higher-ups at the facility. They never spoke to me directly, but their messages found a way to me somehow. The messages consisted of blaming the occurrence on the patient’s condition, saying that stroke patients sometimes react that way. The patient’s medication was also increased, especially his psychiatric medications.
A Gesture of Healing
The one person who truly seemed to understand how much this incident had hurt me was the patient’s wife. His wife, who was a volunteer at the facility, was tireless in her efforts to continue caring for him and many other veterans. She seemed to be his exact opposite in terms of temperament. She volunteered mainly on the day shift, but our paths crossed as the day shift ended and the evening shift began. She too had always been very cordial and respectful to me. The day she confronted me about this incident was no different. I did not intentionally avoid her, but I was not looking forward to encountering her either.
Our discussion took place in the doorway of the patient dayroom. She had always been very direct and that part of her personality was very much in evidence now. She looked me straight in the eyes and said, “I heard about what happened between you and my husband, and I would like to apologize for the awful word he called you.”
I immediately dropped my head and was silent, not because I was ashamed but because I was so full of anger. She continued, “My husband was not a man who used that type of language when he younger, and we did not raise our children to use that type of language either.”
I was still silent, but now we were staring into each other’s eyes. We could both see how deeply this incident had touched me. “I have offered an apology and I can not force you to take it,” she said, “but I hope that you will and that you will continue to care for my husband in the same manner as you have always done.” That was her last statement to me as she gently patted my hand and walked away.
We did speak again after that, but the subject of what happened that day was never touched on. Our conversations were genuine and honest, but I believe we both felt that enough had been said on the subject. Even though I never said anything to her about the incident, she comprehended the depth of the damage her husband had caused by uttering that offensive word.
As much as I would like to say that my treatment of that patient did not change, the truth is that it did. I was still very professional and considerate to him. But all of the things one would describe as “extras” ceased. I never got him up for bingo again and my conversations with him held brevity in my tone.
Time passed and I was transferred to another unit at the facility. But I never forgot that patient or that painful incident. Any time I visited that unit to see past co-workers, I would always peek into his room just to see how he was managing.
I began to hear that his health was declining. By the time I had gathered enough courage to actually step into his room, he had deteriorated to the point where he was alert only to himself and being fed by a nasogastric feeding tube. I stood at his bedside and asked him how he was doing, but all he could do was gaze up at the ceiling and mumble incoherent words. He continued to steadily decline until a co-worker notified me of his death.
Later that week I read his obituary. I was surprised at the sterility of the announcement. There he was in an old picture from his military days, hat cocked to the side, smiling. The obituary mentioned a lifetime of loved ones and military service. It was brief and to the point. He existed, but now he was gone.
I was not sure of my feelings then and I am still not sure of them now. All I knew was that he was dead and our joint legacy of pain had died with him. But it still lives in me.
The point of this personal reminiscence is that we in the nursing profession must ask ourselves how to handle the issue of racism in the nursing workplace, and more specifically, how to handle racism when it is expressed by patients. I guess the first step is to admit that the problem exists. Even when they are in a hospital receiving care for the effects of diseases, aging or traumatic physical injuries, there will always be some individuals who will put their racial ideology above anything they are confronted with. That is their right.
But we professional caregivers of color also have the right and the obligation to stand against such behavior and demand to be treated with respect and dignity.
It’s probably the best working example of universal health care in America. It’s a system that provides millions of people with a widely comprehensive range of health and wellness services–everything from disease prevention programs to dental and optical services to hospital and ambulatory medical care. Its goal is to “ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaska Native people.”
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.”