Earth, Wind, Fire and Water

Earth, Wind, Fire and Water

The logo for the Kahuawake Schools Diabetes Prevention Project in Quebec uses a medicine wheel diagram to illustrate the concept that 'healthy eating habits and daily physical activity can prevent diabetes.'The logo for the Kahuawake Schools Diabetes Prevention Project in Quebec uses a medicine wheel diagram to illustrate the concept that “healthy eating habits and daily physical activity can prevent diabetes.”

“Americans Indians and Alaska Natives feel very strongly about traditional beliefs because they define who we are. Many of us were born and raised in environments where these teachings are passed down. It is not a matter of simply keeping these values and practices alive; it’s a cultural necessity.”

Is this a traditional medicine man speaking? No, it’s a modern-day nurse—Lillian Tom-Orme, PhD, MPH, RN, FAAN, research assistant professor at the Health Research Center, Department of Family and Preventive Medicine, at the University of Utah in Salt Lake City. A member of the Navajo (Diné) Nation, she is also president-elect of the National Alaska Native American Indian Nurses Association (NANAINA).

Who better to understand the significance of traditional American Indian or Alaska Native health care treatments than a nurse who shares the same beliefs, or at least understands them? In areas with large indigenous populations, such as reservations, there is great demand for culturally sensitive nurses who respect and honor native beliefs. In fact, the Indian Health Service, the principal federal health care provider for Indian people, gives preferential treatment to hiring health professionals who are of American Indian or Alaska Native descent. In addition, some tribes own and operate their own health care facilities.

Following American Indian and Alaska Native health care rituals not only keeps the traditions alive, but also provides comfort to patients who believe in and practice them. Even when native patients trust modern health care techniques, traditional treatment methods may offer an additional sense of security.

Common Beliefs

Although traditions vary from tribe to tribe, and even among members of the same tribe who live in different regions, there are basic Indian beliefs about health that extend beyond tribal boundaries. Perhaps the most common is the importance of prayer for maintaining health and treating illness.

“Prayers are emphasized as a part of daily life,” comments immediate NANAINA Past President Bette Keltner, PhD, RN, FAAN, dean of the Georgetown University School of Nursing in Washington, D.C., and a member of the Cherokee tribe. “In some tribes, it is inappropriate to pray for oneself—the beneficiary of prayers will be another person. This practice emphasizes how important family and community is in American Indian culture, because you cannot pray in isolation.”

Similarly, American Indian and Alaska Native cultures revere elders. People of advanced age are viewed as special because of their life experiences and wisdom. They often serve as counselors to communities and are the proponents of tradition because of their direct ties with the past. American Indians and Alaska Natives also consider their entire tribe as an extended family.

One of the most important members of a tribe is the medicine man or woman. Although patients of Indian descent may visit a modern health care clinic regularly and even spend time in the hospital when necessary, many also want to be seen and treated by a traditional healer.


However, many patients do not realize they have the right to use traditional medicine in a hospital setting—a cultural communication gap that American Indian and Alaska Native nurses can help fill.

“Some older patients don’t ask to see medicine men, so nurses should offer to contact one for them,” suggests Dottie Whipple, LPN, a member of the Dakota/Lower Sioux tribe who works for the IHS in Martin, S.D. “When I worked in [a health care facility in] northern Minnesota, we were able to bring in a medicine man or someone to pray with the patients.”

Natural remedies, such as herbs and roots, also play an important part in the healing process. Many American Indians or Alaska Natives drink teas brewed from herbs to maintain good health or to treat ailments. Spending time in sweat lodges is another popular practice, especially for treating drug or alcohol abuse; the heated environment and the sweating are believed to purify the body. Ironically, tobacco is often used in healing ceremonies because it is viewed as a gift from the earth that can cleanse the environment and is a medium of communication with the Great Spirit.

Minority nurses who share this cultural heritage not only have the advantage of being aware that Indian patients may be using these treatments, they also may be able to help patients use these remedies in combination with modern health treatments.

Another widespread Indian health belief that is finding its way into modern health care practice is the medicine wheel or circle of life—a diagram of a hoop or circle divided into four sections, representing mental, physical, emotional and spiritual principles. The number four itself is considered sacred in Indian culture, as there are four primary laws of creation—Life, Unity, Equality and Eternity—as well as four directions and four seasons. Other medicine wheels are based on the four traditional forces of nature: Earth (sustenance), Wind (momentum), Fire (energy) and Water (cleansing).

Because the medicine wheel combines several aspects of life, doctors and nurses who work in American Indian or Alaska Native communities are increasingly using medicine wheels to develop culturally competent health care education and treatment programs. For example, Vera Franklin, CADC, executive director of the Ahalaya Native Care Center in Oklahoma, uses a “recovery medicine wheel” to counsel chemically addicted patients living with AIDS. The Kahnawake Schools Diabetes Prevention Project, which serves a Mohawk community near Montreal, Canada, is one of several successful programs that use the circle of life to teach healthy lifestyle habits.

There are a number of common beliefs surrounding death as well. Indian nurses who understand these beliefs can comfort and communicate with their patients more effectively than nurses without this cultural awareness. According to Erna Johnson, RN, director of nursing at Parker Indian Hospital in Parker, Ariz., and a member of the Quechan tribe, one Navajo belief is that when people die at home, their spirits remain in the home; therefore, many patients choose to die in the hospital. Tom-Orme adds that Diné women who view the hospital as a place to die may choose not to give birth there.

Johnson notes that one Pima belief that is shared by several other tribes is that any body part that is removed during life, such as by amputation, must be put back with the body when a person dies. Otherwise, the person will go on to the afterlife incomplete. In Papago (Tohono O’odham) culture, when a person dies, the family bathes the body and combs his or her hair. All hair that comes out in the brush or on the floor must be bound and placed with the body so the spirits will take the deceased person with them.

Complementary Care

Today’s American Indian and Alaska Native nurses often combine traditional remedies with modern health care treatments, giving their native patients the best of both cultural worlds.

“I combine traditional and modern treatments for my own care and for others, too,” Whipple says. “When my husband gets a cold, he takes cold medicine; I eat my [medicinal] berries. Our reservation was very small, but I grew up with all the ceremonies, and my dad used herbs. I didn’t go to the doctor very often.”

However, just being of American Indian or Alaska Native descent doesn’t necessarily qualify a nurse to make decisions about using traditional remedies or to know how to combine them with modern treatments, Keltner cautions. Making the correct choice requires nurses to consider several factors, including their own capabilities.

“Nurses must assess the patient’s needs and recognize that some conditions require certain treatments; for example, appendicitis might require surgery. On the other hand, some conditions could be complemented with traditional healing methods to foster recovery,” Keltner explains. “In those cases, an Indian nurse must evaluate whether to refer the patient to a traditional healer or whether she is capable of providing the healing herself.”

The former NANAINA president goes on to emphasize that health is a cycle—a person may experience illness and then have a period of good health. She says that American Indian and Alaska Native nurses are “keenly aware of the spiritual aspects of health and illness” and understand that spirituality can “facilitate good health.”

When traditional healers are allowed to work in a hospital setting, they must be given the space and tools they need to do their jobs. Johnson, who spent a long time working with the Tohono O’odham tribe in Arizona, recalls that at the hospital where she worked, there was a room set aside for healing rituals. The hospital staff removed all the oxygen tanks from the room so that the medicine man could light candles for his rituals.

“It makes sense that we incorporate these [traditional] values into our practice,” Tom-Orme says. “A friend of mine put this very nicely when he said that, ‘as native professionals, we have to understand that traditional medicine works from within to the outside.’ Modern medicine, in contrast, works from the outside inward as we ingest medication into our bodies.”

Getting the Point Across

Because linguistic competence is an important aspect of providing culturally competent care to ethnic minority patients, American Indian and Alaska Native nurses who speak the native languages of their patients are in high demand. Most health care facilities located on or near reservations, or in areas with large Indian populations, employ a number of nurses and other personnel who can translate for patients.

“When an American Indian is very ill, that person may revert back to his or her native language, even if that language is not used very often,” Whipple explains.


On a deeper level, getting patients to understand the medical consequences of their actions poses a challenge for nurses. Lifestyles and traditions that have been handed down from generation to generation—such as the traditional use of tobacco—factor into a number of prevalent health problems among American Indians. At the same time, many illnesses that are serious concerns in Indian communities, such as diabetes, high blood pressure and cancer, are relatively new to this population, because they were brought to this country by immigrants from Europe. In fact, Indian languages don’t even have a word for “diabetes” or “cancer.”

“This is why we are struggling with the problem of diabetes in our communities,” Tom-Orme comments. “Nurses must take into consideration the broader framework to explain diabetes and other chronic and persistent health problems. Indian people are now beginning to discuss these issues in public forums. The Navajo Nation is trying to standardize the diabetes ‘language’ so that we are all speaking about the diabetes pathology and health concepts the same way, to avoid misunderstanding and to improve outcomes.”

One way that American Indian and Alaska Native nurses are able to educate their patients to prevent and treat illness is by showing genuine interest in the community’s health. On many reservations, community educators and outreach programs have proven to be effective in getting patients and their families to comply with prescribed care. The Indian Health Service and other health organizations have established successful programs in which nurses or other caregivers visit patients’ homes.

“I see a lot of denial, especially in people with diabetes,” Whipple says. “At the IHS, we have outreach programs that continue to follow up with patients. We send letters or make home visits. A lot of patients finally become convinced that [health care] is important because someone cares enough about them to keep coming back.”

Blending old traditions and new techniques into an effective health care practice is a challenge even for nurses who are intimately familiar with American Indian beliefs. For nurses who have not grown up in this cultural environment, college and nursing school programs can help familiarize them with native beliefs—but Keltner warns that such information does not prepare nurses to provide traditional Indian remedies.

“One of the risks is that in an already-crowded nursing curriculum, students will only get an overview or survey,” she explains. “That does not give you the knowledge to go out and practice those methods. Nevertheless, nursing should be an interactive and personal profession. There’s no way to ignore the responsibility of learning about other cultures.”

With so much of their culture having been destroyed, lost or assimilated into other cultures, it’s no wonder that American Indians and Alaska Natives want to hold on to their traditional health care practices and beliefs. Nurses who can integrate these beliefs effectively into their modern practice are not only helping their patients to stay healthy but are also helping to preserve an important part of the past.


Careers in the Indian Health Service

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.

The Details

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.


The Need

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.

The People

“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.’”

The Setting

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).

The Opportunities

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.


The Experience


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.”