A recent Institute of Medicine report documented evidence that minorities in the United States received lower levels of mental health care, even when variables such as insurance status and income were controlled, says Debbie Stevens, P.M.H.C.N.S.-B.C., a doctoral student at Emory University’s School of Nursing in Atlanta, Georgia. That’s because nurses play a major role in helping reduce these disparities by educating patients, families, and their communities, Stevens says.
Overcoming cultural barriers
Finding treatment for an illness, such as depression, can be difficult for members of minority groups because they may face stumbling blocks to care, says Vicki Hines-Martin, Ph.D., R.N., F.A.A.N., a professor in the University of Louisville School of Nursing in Louisville, Kentucky.
A major barrier is a perceived cultural stigma of mental health issues. Hines-Martin says some minority populations don’t talk about suicide or depression because it’s seen as shameful. “You may have people who say, ‘I know about suicide, but it has nothing to do with my family or my group,'” she says.
Another problem is that many people may not understand the seriousness of their needs, says Harriett Knight, R.N., a nurse at Sinai Hospital in Baltimore, Maryland. Some people may initially seek an appointment with a specialist, but if treatment involves ongoing medication for an illness, such as depression or schizophrenia, the patient may be resistant to taking the drug as prescribed, or they don’t fully accept that they should continue to take it, says Knight.
Sylvia Hayes R.N., M.S.N., is a nurse in the mental health unit of Peninsula Regional Medical Center in Salisbury, Maryland. She says many patients she sees also don’t accept that mental health is a specific medical science. “They tend to believe their issues are caused by a physical problem,” she says. So they may seek help for a persistent headache, when the real issue may be anxiety related, she says.
In many cases, if a patient realizes that his or her medical issue does involve mental health, they may face another barrier—the fear of being stigmatized. Hayes says she’s seen many African American patients who are afraid that they’ll be “labeled” if they admit to having mental health issues.
“They don’t want to be considered ‘crazy,’ and their family doesn’t want them to be considered ‘crazy,'” says Hayes. “They may be afraid their family will isolate them if they seek help, because then they’ll become an embarrassment.”
Of course, many families support their loved ones suffering from mental illness, regardless of any perceived social stigma. In fact, when relatives are accepting of their loved ones and are willing to help them find care, they can be a vital part of the recovery plan. Many patients will even turn to family members for help before they turn to the medical system, says Hayes. This is good, as long as well-meaning relatives encourage patients to seek professional help when necessary. “It can be a negative if the family delays the patient from receiving the treatment they need,” she says.
Many families actually hold the key to helping patients understand their medical histories, Hayes says. “I’ve seen people with family secrets. They had an uncle or aunt who may have dealt with the same mental health issue,” she says. But if the family shunned that aunt or uncle, the patient may not be as open to finding help.
Family cooperation is also important in treating children and teens. Hayes says many mental illnesses are present at a young age. “I’ve worked with kids as young as two years old,” she says.
However, it may be difficult for well-meaning families to receive satisfactory care. A recent press release from the National Alliance on Mental Illness (NAMI) reports “63% of families reported their child first exhibited behavioral or emotional problems at seven years or younger,” but at the same time, “only 34% of families said their primary care doctors were knowledgeable about mental illness.”
Language and cultural obstacles present another challenge for mental health patients. If a person can’t find a medical professional they can simply talk to, they are less likely to seek medical care, says Patricia Lazalde, Ph.D., Director of Behavioral Health at San Ysidro Health Center in San Diego, California.
San Ysidro serves many Spanish-speaking Latino clients, so it’s important for minority nurses to be able to speak Spanish too, she says. “Minority clients may come in with a variety of stressors, but due to language issues they often don’t seek help until it reaches a crisis,” says Lazalde.
Immigrants of various backgrounds encounter similar stressors. In Louisville, Kentucky, there are increasing numbers of members in immigrant and refugee communities, particularly form Somalia and Myanmar, says Hines-Martin. “They’re newcomers, and they’re dealing with the stressors of changing from one environment to another,” she says. “How they deal with these stressors and whether they want to talk about them is important.”
Members of minority populations may also postpone or avoid seeking care for mental health issues, Hines-Martin says. It’s not so much related to an ethnicity or racial group, but it’s associated with people who hold more traditional values related to their culture, and are less likely to follow mainstream care, she says. “People who are less acculturated into the general population may be less likely to seek help if their culture says it’s not something they should do.”
Financial stress and mental health
The slow economy is also creating a barrier to care for some people, even as it’s identified as a stressor for many. Patients are dealing with the stress of lost jobs, eviction, and foreclosure, says Hines-Martin. She recently completed a study of 127 people in a low-income area and found that poorer residents had almost double the rate of depression as the general public.
“When you look at the economic factors they have to deal with, it makes perfect sense,” Hines-Martin says. The stress of constantly figuring out how to survive can wear down a person, and those factors are associated with depressive systems, she says. “If you have problems in several areas of your life, it can affect your mental health.”
Obviously, financial setbacks don’t always cause mental illness, but they can exacerbate problems in people who are vulnerable, says Knight. “A lot of patients don’t know they’re getting sick until there’s a trigger,” she says. For example, a person may get a call from their mortgage company informing them that they’re being foreclosed on, and they can’t handle their emotions, she says.
Lazalde agrees that whenever there is a loss of financial status within the family, nurses tend to see people with increased levels of depression and anxiety, particularly with wage earners.
“Traditionally, Latino males are the primary breadwinners for families, so the loss of a job and the inability to properly care for the family can really create an additional sense of anxiety, depression, and worry. It’s because they can’t live up to the more traditional roles that they would typically fulfill for the Latino family,” Lazalde says. As a result, there’s an increase of male Latinos coming to seek help for depression and anxiety, she says. The issues affect the entire family. “It creates marital problems. Parents are fighting, and we see the kids coming in with levels of anxiety as well,” Lazalde says.
Residents often have to move out of their homes and move in with relatives and extended family because of financial problems, she says. “Family members have to change schools and meet new friends, and there are not a lot of places they know to go to in terms of seeking resources and finding a shoulder to cry on,” Lazalde says.
Financial problems can also limit access to health care, including treatment for mental health needs. “Many clients are losing medical or health insurance coverage,” says Lazalde. This means fewer people can afford their doctor visits, and they have a more difficult time paying for their prescriptions.
Immigration issues are another stressor in many minority communities. There’s a lot of anxiety and depression when people hear about immigration reform on the news, and they’re worrying about what the outcomes and changes will be, says Lazalde.
“Many of our families are being impacted. A number are split up, with half the family living in the United States and the other half in the native country,” Lazalde says. As a result, wage earners have to support two homes, while they’re responsible for the cost of attorneys and other fees. “They have the stress of keeping the family together.”
One way nurses can help patients deal with their stresses, and improve mental health care overall, is to become active in the communities they serve. This helps build trust between residents and medical professionals, says Hines-Martin.
She says that’s a goal of the Office of Disparities within the University of Louisville’s School of Nursing, where she serves as the center’s Director. The office was started because the school of nursing identified a need to focus on how nursing education, practice, and research could help populations that experience disparities in health, Hines-Martin says.
The Office of Disparities sponsors a variety of programs, including faculty and student activities. Hines-Martin’s most recent project involves working with an entire low-income public housing community. “There are about 700 people in a one-block area,” she says. “It’s a way for us for us to see how economics, food, and trans-generational housing affect how people cope.”
Hines-Martin and her nursing students have found they don’t necessarily see people who are actively engaged in behaviors that are detrimental, such as self-inflicted violence or substance abuse. “But I do see people taking risky behaviors because they don’t care anymore,” Hines-Martin says. These people put themselves in dangerous situations, such as drinking excessively, and the drinking is actually related to depression or a depressed state of mind, she says.
There are many challenges, but the program is yielding results for patients who receive care, says Hines-Martin. She says she’s seen people who received help for psychological conditions and didn’t need to be readmitted to a medical facility after receiving treatment.
There’s also been a decrease in the number of people who have been evicted from their homes because of problems that could be tied to mental illness, such as drug use, says Hines-Martin.
“The community is in partnership with us,” Hines-Martin says. “We’ve learned that people are really invested in having a better understanding of their lives and mental health. It makes it easy to partner with them and invest in them.”
Another way to help build trust is to work with other professionals and community leaders to help educate the population about mental health topics. “Many Latino families aren’t likely to go to a behavioral health specialist initially. Instead, they’re more likely to seek help from clergy or a medical doctor,” Lazalde says. With regards to minority nurses, if they are connected to these influencers, they can help patients find needed behavioral care more quickly, she says.
Identifying red flags
Finding good mental health care is not simply a task reserved for nurses who specialize in behavioral health. Minority nurses in all specialties can help identify red flags that a patient may need a referral for a behavioral health specialist, Lazalde says.
When a nurse in any practice area sees a patient, he or she should look for issues such as a high frequency of usage, she says. The primary care doctor is usually the first person a potential mental health patient will visit, Lazalde says. If a patient has historically only visited the doctor’s office once or twice a year, but now they’re visiting two or three times a month, that’s a red flag, she says. These patients tend to have physical complaints with no apparent cause, so the real issue could be stress or anxiety related, she says.
Minority nurses also need to pay attention to comments patients make during their visits. “They may see a doctor and complain about a headache, or pain in the chest or back, but at the end of the session they bring up family problems,” Lazalde says.
Another red flag could be visits from multiple family members. “If you’re seeing a mom, dad, and siblings for physical problems, all within the space of a month, it could be a sign that there’s some sort of turmoil in the family,” Lazalde says.
And nurses shouldn’t wait until the visit is nearly over before addressing mental health issues. “I think it’s really important for nurses to ask questions early on,” says Lazalde. “Ask how things are going in the family and at home. If the questions are addressed by the medical provider or nurse, it normalizes the situation and allows the family to speak more freely,” she says.
When nurses are rushed for time, sometimes really important pieces of information fall through the cracks. This can be prevented by having a patient fill out a survey at the start of their visit, Lazalde says. She encourages the use of a questionnaire, such as the Generalized Anxiety Disorder 7-item scale (GAD7), to help assess a patient’s mental health needs. “It only takes a few minutes and can be completed in the waiting room, and it doesn’t take away the nurse’s time,” she says.
If it’s determined that a patient should receive specialized care, Lazalde recommends that referrals be “normalized.” For example, when nurses make a referral to a provider who’s an oncologist, it’s normal because the oncologist is simply a member of the health care team, she says.
“So we have to find a way to make the behavioral health provider a member of a team. Instead of making the client feel as if there’s something wrong with them when they receive a referral, they’ll know that they’re just meeting another member of the team,” she says.
Lazalde also has another important piece of advice for minority nurses: don’t give up on your patients. “It often takes more than one referral to be successful. Sometimes we have to refer the patient three, four, and five times,” she says. If nurses approach their roles knowing that it takes multiple referrals before they reach a successful linkage to the other provider, then nurses may be less likely to get discouraged, she says. “We’ll know that the family hears the referral more times and there’s a higher likelihood the patient will go and complete the referral and receive the services they actually need.”
Perhaps the most disappointing barrier minorities face are the ones caused by the attitudes of medical professionals. Minority nurses can exhibit the same biases about their patients as anyone else, and if they’re not careful, they may start to form negative opinions that could affect their levels of care, says Stevens. “Just because a nurse is a minority doesn’t mean they’re immune to stereotyping,” she says.
Some nurses, particularly those who serve low-income communities, fall into the trap of assuming that some poorer patients check into medical facilities to access prescription drugs, three square meals, or a warm bed, she says. “I’ve heard people say ‘the patients are looking for three hots and a cot,'” Stevens says.
These biases are often reinforced when patients have high rates of repeat visits, she says. But despite the challenges, many minority patients who do receive appropriate care become better and are able to function in society, she says. Minority nurses must provide the best service possible by making a sincere effort to view each patient as deserving of quality medical attention, Stevens says. “Nurses have to fight to eliminate negative stereotypes they see, even if they may have had those same stereotypes themselves,” Stevens says.
Translating policy into practice can be difficult because of how pervasive some biases are, but it can be fought the way any ethnic or cultural stereotype is fought, says Stevens. “It starts with education and awareness.”
Some patients will be difficult, Stevens concedes. But if mental health care is your specialty, you should remain confident that you are helping your patients. Standards of care have to be the same, regardless of who the patient is or where he or she comes from, Stevens says.
Minority nurses are specially suited to help break down barriers and stigmas, build trust among their communities, and help their patients live the best lives possible.
Some two million American Indians and Alaskan Natives in the United States are eligible to receive health care through tribal health programs. As a result, there are a great many opportunities for nurses to provide care for Indian patients living in tribal communities, in a wide variety of settings-from tribal clinics, Indian Health Service (IHS) facilities and tribally run health care institutions to reservations, tribal trust lands and urban clinics.
According to the most recent National Sample Survey of Registered Nurses, there are only about 13,000 American Indian/Alaskan Native (AI/ AN) nurses in the United States-not nearly enough to provide health care for the entire Indian population. As a result, tribal communities must depend on the collaborative efforts of both Indian and non-Indian nurses if they are to receive adequate, accessible and culturally competent nursing care.
But no matter what their race or ethnicity, all nurses who work with Indian populations in tribal settings must understand and appreciate the political and health history of AI/AN tribes if they are to truly provide effective, culturally sensitive care. Many nurses who work with tribal communities-even if they are Native Americans themselves-may not fully understand why Indians have different health resources than the general population, because they lack awareness of the political and historical issues involved and how these issues directly impact health care delivery.
There are over 550 federally recognized Indian tribes in the U.S. and each tribal government is set up differently. Many of these tribes are now managing their own health care programs; some tribes even have their own health insurance. Tribal governments frequently include health boards that make policy decisions affecting health care in general and nursing in particular.
Trust responsibility, tribal sovereignty, tribal politics and self-governance are all terms that are commonly used in Indian communities, including their health care programs. Both Indian and non-Indian nurses who want to work successfully in tribal settings need to understand what these concepts mean and how they affect their roles as nurses.
To understand why Native Americans have tribal health programs that are set apart from the rest of the U.S. health care system, nurses must understand that there is a trust responsibility, established by treaties, between the federal government and Indian tribes. In the 1830s, Chief Justice John Marshall coined the term “domestic dependent nations” to describe the fact that tribes are under the protection of the United States.
This promise by the federal government to provide for the tribes led to the creation of the Indian Health Service, an agency of the U.S. Department of Health and Human Services that is responsible for providing federal health programs to American Indians and Alaskan Natives. It is important for nurses to understand that by working in Indian health care programs, they are helping to fulfill the government’s trust responsibility toward the Indian nations under its care.
Tribal sovereignty means that Indian tribes have the status of independent nations, recognized as such by the federal government, with the inherent right to govern themselves. Today, 500 years after their first contact with Europeans, tribal nations remain distinct political entities. Although they function within the states in which they are located, each tribe operates internally as a sovereign government that deals with the federal system on a government-to-government basis.
The independence and power inherent in tribal sovereignty was strengthened during former President Clinton’s administration, when he decreed that tribal nations and the federal government must consult jointly on issues that directly affect tribes.Tribal sovereignty is an important part of Indian health care, because it is through these government-to-government relationships that tribal nations negotiate for federal health care funding. As the concept of tribal sovereignty has become better understood by the federal government, tribes have increasingly demanded and gained more control over the right to manage their own health care issues and programs-e.g., by taking over the management of former Indian Health Service facilities (see “Self-Governance”). In turn, the IHS has begun downsizing its structure and encouraging more Indian nations who receive federal funding to manage their tribal health programs directly.
Many tribes, such as the Chippewa Cree of Montana, have committees or boards that directly oversee health care issues and the dispersement of health care funds. An important role of nurses who work in tribal settings is to advise and educate tribal politicians about health issues that will affect the board’s decision-making on tribal health policies. In fact, nurses are often the politicians’ sole source of health-related information.
A notable example of this is the recent Supreme Court decision in which the Mille Lacs Band of the Ojibwa tribe regained their tribal rights for hunting and fishing on Indian lands. The influence of public health nurses who were working with the tribe to promote awareness of healthy lifestyles helped tribal leaders identify this as a health-related issue: By being able to hunt and fish, the Ojibwa people were able to return to a more traditional diet, which would help reduce the risk of diabetes in their community.
Self-governance, a tribal rights movement that emerged in the 1980s, refers to a tribe’s decision to manage its functions and programs itself, as opposed to having them managed by a federal agency or administrator, such as the Bureau of Indian Affairs. A group of 10 tribes, including the Cherokee Nation, took the lead in establishing themselves as self-governance tribes that would receive funding from the federal government but decide for themselves how to spend that money. Today, more than half of the nation’s tribes identify themselves as self-governance tribes.
The goals of the self-governance movement are to promote self-sufficiency, establish accountability, reduce bureaucratic red tape and change the roles of federal agencies as they relate to tribes. In the specific context of health care, self-governance means a tribe has exercised its right to run its own tribal health programs, rather than receive health services provided through the IHS.
Native and non-native nurses alike are needed to work in both tribally run and federally run Indian health programs. Tribes view nurses-and Indian nurses in particular-as knowledgeable health care professionals who can play a vital role in helping to direct and supervise tribal health care programs. Therefore, nurses who plan to work in tribal settings must understand that they may be expected to provide not only clinical patient care but also the management expertise needed to actually run clinics or other facilities.
Above all, nurses must understand that tribes know best when it comes to their own health care needs and how to allocate their resources and energies in the right direction. Armed with this insight and wisdom, nurses have the power to make unlimited contributions to improving the health of American Indians and Alaskan Natives.
Captain Pelagie “Mike” Snesrud, RN, is a Lakota Sioux Indian and a commissioned officer as a public health nurse for 27 years, and in January 2002, she was appointed to a key policy-making position at the Centers for Disease Control and Prevention is Atlanta. She is the Senior Tribal Liaison for Policy and Evaluation in the Office of the Associate Director for Minority Health.
Essentially, she is charge of the CDC’s health promotion and disease prevention efforts specifically for members of Indian tribal communities. As her title implies, a large part of her role is acting as a liaison between the federal government agency and the nation’s 569 federally recognized Indian tribes, which are self-governed sovereign nations that have a government-to-government relationship with the United States.
Her nursing career over the past 30 years has been remarkable and determined, showing a singular drive and ambition to serve the Indian community, be a model to other Indian nurses, and be a wife and mother to four children. She has successfully “done it all” and an examination of her professional path demonstrates it is no accident that she has arrived to her destination as a national leader in Indian health today.
She graduated from Winona State University in Minnesota in 1974 with a BSN, then worked as a public health nurse for the Bloomington Health Department for four years. Her goal was to work with American Indian people after she had obtained sufficient experience in the field, and she set out to acquire the experience she felt she needed.
In 1978, she transferred to Kansas with her husband, a teacher, and worked for the Douglas County Health Department. Within six months, she faced her first big professional disappointment. She said she was dismayed at the facility’s level of competency, which did not measure up to her experience in Minnesota, a leader in the nation’s public health. She said that although Douglas County was very rich, large numbers of minorities did not have adequate healthcare available to them, and the situation became too frustrating for her to continue nursing there.
She then transferred to Lawrence Memorial Hospital and worked on the surgical floor. Here she learned she did not want to be a surgical nurse long-term, and her resolve to become a public health nurse returned. Patients came to her only when they were very sick and left shortly after surgery. “We didn’t get to see the whole picture, and I learned I preferred to interact with clients in their environment where they were in control,” Mike said.
After having her fourth child in 1980, she was recruited by Haskell Indian Junior College in Lawrence, Kansas, which served a significant percentage of American Indians. Many of her hospital Indian patients were also treated at the college’s clinic, and she saw an opportunity to forge a closer relationship between the two institutions. She decided to keep working about 30 hours per week at the hospital, while accepting her new appointment at the college, partly to provide more income for her growing family and partly to help enhance the communication between the two groups. Mike played an important advisory role in the expansion of the college’s nursing program and in 1981, its LPN program turned into a two-year RN program. As a clinical instructor at Haskell, she was able to regularly bring a troop of nursing students to the hospital on a weekly basis.
Unfortunately, there was a lack of institutional support for the nursing program to flourish and in two years, the program folded altogether, which was a huge disappointment to Mike and the college. During this period, however, the health director at Fond du Lac Reservation in Minnesota began to call her every six weeks to recruit her to head his public health program. His goal was to recruit a Native nurse from Minnesota because he thought such a person would have a greater commitment to the Indian people. So in 1982, Mike accepted the position and moved back to her roots in Minnesota where she stayed to nurture her public health career and raise her family for the next 20 years.
When she arrived, the program was in its infancy stage with only eight health and social services personnel. When she left, there were 48 staff under her; 75 percent were Native people from the community. Their maternal-child health program saw 98 percent of pregnant mothers in the community. The child check-up program provided a minimum of six home visits during the child’s first year, which improved immunization rates from 30 percent to more than 90 percent. They developed a car-seat program in which every child received a car seat. The Fond du Lac Human Services division became one of the premier programs in the nation, and its tribal human service became an example in how health staff could collaborate with tribal counsel to satisfy health needs.
In 1993, she became the first president of the National Alaskan American Indian Nurses Association (NAAINA). Between 1995 and 1997, she was chair of the Indian National Council of Nurses Administration, which included 300 nurse administrators throughout Indian country. She is also the project officer of the American Indian Higher Education Consortium, the mouthpiece of the 35 tribal colleges in the nation. They play an important role in recruiting local community members to pursue further education.
At last year’s NAAINA national summit, Mike called her CDC appointment “an amazing opportunity” for an American Indian professional nurse. “Things change when Indian people get inside federal policy-making organizations, and it’s exciting to see that happen,” she said. “It’s a great opportunity to be inside the CDC and see the programs that are developing, and be an advocate who says ‘What about tribes?’ and build a circle of players that can come together to help Indian people.”
Q: When you arrived at Fond du Lac in 1982, how was the atmosphere?
A: There was distrust with the nursing and medical staff among the Natives. Many community people came to check on them and reported them to the county, which sometimes took away their children and disrupted their family life. We had to earn the trust of the tribal counsel. Likewise, we didn’t have a hospital, so native clients were referred to one of four non-Indian hospitals. There was a lot of prejudice and resentment on both sides because of historically bad relationships.
Q: How were you able to make improvements at Fond du Lac?
A: I helped develop cultural sensitivity with our health care team—the home health aides, the community health representative, the nursing and physician staff. Many who were not Indian came with a different understanding of where the Indian community was coming from. Some of the elderly’s concept of health and illness was very different from the physicians’. Many did not go for healthcare until it was an emergency. Clients wouldn’t follow their plan of care and there was no follow-up. Health staff learned to do follow-up, to provide transportation, to help get financial assistance.
Q: Tell us about your Indian background.
A: I am affiliated with the Lakota Sioux Tribe on my grandmother’s side and the Hochunk tribe on my grandfather’s side. I grew up in Shakopee, Minnesota, and our band is named after Chief Shakopee. Our small reservation nation wasn’t well developed. One thing that really stands out in my mind is the prejudice that was directed at me and other Native people as I was growing up. As long as we were quiet and insignificant, that was fine. But when we spoke up, there was conflict.
Q: What inspired you to become a nurse?
A: I had an older sister who was an RN. She was my role model and she’s been practicing until about two years ago, well into her 60s. I was about five years old when I attended her graduation from the Mayo Clinic, and I knew then that I wanted to get involved in healthcare somehow. My sister became a head nurse at the Shakopee Community Hospital and I began candy striping under her until I was about thirteen. During high school I became a nurse’s aide. I saw that nurses had the ability to impact patients more intensely than physicians, so I opted to become a nurse.
Q: What are some of the challenges for Indian nurses?
A: It’s a major issue to recruit American Indian and Alaskan nurses into tribal positions because of the nursing shortage. Many Native nurses are recruited by other agencies that can offer better salaries and hire them quicker.
Q: How would you describe Indian nurses?
A: My feeling is that most Native nurses are the cream of the crop because they had to go through many personal and professional challenges to get to the point where they’re at. Almost 90 percent of Native nurses are the main breadwinners for the family. That means they juggle the scheduling of a career and their children. Many are single mothers who passed a lot of hurdles to get through nursing school.
Q: Why do you think Native nurses are usually the main breadwinners?
A: Maybe it’s the caliber of the women. The kind of person who aspires to be a nurse is a strong, caring person. They have juggled their lives to serve their community, to make an impact, to be a mother and member of their family. They do it all.
Q: What was it like for you to be a nurse, wife, and mother of four children?
A: I’ve been the main breadwinner in my family. I’ve also been happily married for 32 years. My husband is a teacher, and teaching doesn’t pay well. Because of my high commitment to my family and community, I do what needs to be done. I work the amount of hours necessary to be successful in both those realms.
Q: Tell us about your children.
A: I have twin daughters, 28 years old. Tara graduated from the University of Minnesota as a nurse practitioner and is now at the Mayo Clinic. Heather has a degree in business and is at Merryl Lynch. Matthew is 26 years old and is playing professional hockey with the Manchester Monarchs, the Los Angeles Kings minor team. Jeremiah is 23 and he’s a junior at the University of Wisconsin completing a degree in personal and corporate health.
Q: How did you ultimately move to the CDC?
A: I was ready to expand what I was doing. Different people had been tantalizing me to work on the national level. I was not considering a move until my children essentially finished college so that they were secure with their desires.
Q: What are you doing at the CDC?
A: I am a public health analyst with American Indian and Alaskan Natives. When I came on board, my role was expanded with the additional title of senior tribal liaison for policy and evaluation. One of my roles is to take a draft policy written by an internal tribal consultation workgroup and take it into Indian country to ask elected tribal leaders what they thought about it so that they could give specific guidance and recommendation.
Q: Can you describe your meetings with the tribal leaders?
A: We did a regional consultation series through November 2002. We had 11 regional consultation meetings and send invitations to all the 569 tribal chairmen to attend. We had a good showing. We’re now reviewing the transcripts, but those recommendations from the tribes will constitute the CDC’s tribal consultation policy.
Q: What are some of the basic issues among Indians?
A: We need to develop a Native public health workforce with experience and training to deal with the unique issues in their area. We not only need Native nurses, but we also need Native epidemiologists, statisticians, environmentalists, and scientists. We’re also working to enhance the cultural competency of the CDC staff. Although the CDC has some of the best and brightest health professionals, many are not aware of the uniqueness of the 569 tribes and the important role that the tribal council plays in carrying out the health programs on their reservations.
Q: What are some of the common health problems among Indian tribes?
A: For hundreds of years Native people have not accessed quality healthcare. They are very entrenched in poverty, have a lack of resources, and barriers to accessing them. They have chronic diseases and infections. They’re not used to using car seats and wearing seatbelts. They also mix alcohol with driving.
Q: What advice to have for other Indian nurses?
A: Stay connected with the community people and then be willing to extend yourself and go to a totally different environment. Government agencies, like the CDC, the National Institutes of Health, the Food and Drug Administration need Native people working intricately within their agencies to remind them about the sovereignty of tribes and the important role that tribal councils play.
Q: Anything else you’d like to add?
A: It’s an exciting opportunity to be considered part of such an astute group of health professionals at the CDC. Working with the tribes is a big challenge, but I’m learning from the success stories that have occurred with other minorities and how we can translate those successes to the tribes.
It is certainly no secret that American Indians suffer disproportionately from many serious health problems, including diabetes, cancer, AIDS and substance abuse. Nor is it news to most nursing professionals that more research into the causes of these health disparities is urgently needed in order to develop effective, culturally competent prevention and treatment programs. But despite this common knowledge, American Indian populations and their culture are familiar yet foreign to much of the nation’s nursing community.
Because Indians are severely underrepresented among the ranks of nurse scientists, many non-Indian nurses have conducted research in Indian communities–or have attempted to do so. The key factor in determining whether such research projects will be successful or fruitless is the nurse’s awareness of, and ability to overcome, the unique challenges involved in working with Indian populations. Many of these challenges relate specifically to the issue of conducting research in a manner that is culturally sensitive to Indian communities’ needs.
The first challenge researchers must meet is that of establishing trust and proving their commitment to conducting research in a culturally respectful way. Many Indian tribes are distrustful of outsiders and do not welcome researchers into their communities. Furthermore, Indian communities have been the focus of hundreds of research studies over the years but have not always had the opportunity to benefit from these projects and their findings. Because of this overuse of Indian communities, many tribes have become closed to non-Indian researchers.
Nurse researchers need to understand that it takes time to build trust. Sometimes, getting a research project started in a tribal community can take one to two years–or more–of preparation before the researcher can even begin the study. Therefore, researchers not only need to be committed to overcoming barriers of distrust but must also be willing to commit time to getting access to the Indian community.
Getting It Right
There are several culturally sensitive steps a researcher can take when preparing to conduct a study in an American Indian community. The first step is to identify what type of Indian community it is–a reservation, a non-reservation community, an Indian nation, a tribe, a band, a federally or non-federally recognized tribe or an urban community.
This knowledge is important because there are cultural and historical differences between these various types of communities, such as languages, degrees of assimilation, means of identifying tribal members, and sustained cultural practices, to name a few. There are also differences in community size, tribal governance and the tribe’s relationship with the U.S. government. Researchers must be familiar with these distinctions in order to address the community and its members knowledgeably and appropriately.
For example, an Indian reservation is a self-contained tribal entity with its own government, governing rules and land base, while a non-reservation Indian community–such as those in Oklahoma–may have a tribal government but not the land base. The terms “Indian nation” and “tribal nation” refer to the largest Indian communities, while “band” usually refers to smaller groups of people within one tribe–e.g., the Ojibwe tribe has many bands, and the governing structure for each band may vary. Therefore, members of an Indian nation may be offended if an outsider calls it a band or a tribe, and vice versa.
Researchers also need to consider the region of the U.S. in which the Indian community is located–e.g., Southwestern, Southeastern, Northwestern, Eastern, state of Oklahoma or state of Arizona. Each region has had its own impact on the history and development of the Indian communities it contains.
For example, in Oklahoma during the territorial days, the state was made up of many Indian reservations. But in the early 1900s these reservations were taken away from the tribes, and each enrolled Indian person was instead given a parcel of land. This change in the land base dramatically altered the way of life for Oklahoma Indians.
In addition to learning as much as possible about an Indian community’s history, structure and culture in advance, a researcher preparing to conduct a study in that community may also want to visit the area. Much can be learned from visiting the community’s cultural center, attending a public Indian event in the community, visiting a historical Indian site, talking to the local Indian people and becoming familiar with the local customs.
When visiting the Indian people, a researcher who is culturally sensitive will ask them how they prefer to be addressed and how they want to be identified. For example, members of the Navajo Nation may prefer being identified as “Diné” rather than “Navajo.”
It’s also important to let the Indian people reveal information about their community in their own way and in their own time. If you ask them direct questions, you might not get answers. Indian people believe in developing a oneness of spirit with another person before information can be exchanged.
Working With What You’ve Got
Another challenge a researcher may need to overcome is the limited availability of resources in an Indian community. Because many tribal communities are poor and do not have economic development, the people who live there generally lack financial resources as well as adequate housing, transportation, sanitation, clothing or food.
Furthermore, many Indian communities are located in remote and rural areas of the country where access to necessary resources and services is severely limited. In the Deep South, for example, there are many small Indian communities in rural areas where there is no public transportation and no emergency services, hospitals, clinics, or physicians nearby to care for the Indian people. These people must drive long distances to receive health care–if they even have a car.
When conducting a research study, these kinds of factors can influence the outcome of the project. For instance, the Indian people may not even be able to arrange transportation to participate in the study. You will have to bring the study to them.
Difficulty in obtaining a large enough sample size is still another obstacle that can prove frustrating for nurses who want to conduct research studies in an Indian community. The largest tribe in the U.S. is the Navajo Nation, which has over 250,000 enrolled members, followed by the Cherokee Nation with around 222,000 enrolled members. Most tribes, however, are much smaller in size, averaging only a few hundred or thousand tribal members. As a result, American Indians are often not included in studies examining significant health problems like breast cancer and lupus, because the sample size is too small to be statistically valid.
It is not always easy to find a solution to this problem. Some experts suggest grouping several small tribes together to increase the sample size, while others argue that this method is not always culturally appropriate and that tribes do not like to be “lumped” together in this way. Another possible approach would be to explain the reason for the small sample size and adjust the statistical significance accordingly. For example, if 50% of the people in a tribe are diabetic, this is a significant finding even if there are only 250 tribal members.
Because of the negative research experiences they have had in the past, many Indian communities are now demanding more respect from outside researchers, as well as a greater sense of co-ownership in the study before, during and after it is conducted. To be culturally sensitive, nurse researchers must strive to develop a more “equal” partnership with the tribe.
Traditionally, many researchers have only wanted tribal communities to assist with recruitment of subjects and nothing else. Once the data was collected, the researchers never returned or followed up with reporting the findings back to the community. The tribes did not know the outcomes of the studies. The researcher benefited from the study while the tribe received few, if any, benefits from its members’ participation in the project.
Tribes are also raising questions about who owns the data from a research study conducted in their community and are demanding more control over how the data is handled. In some studies, the findings were not only published without any input from the tribal community but also published in a way that reflected negatively on the tribe.
To cite just one example, a researcher who conducted a study on health problems occurring in an Indian community in the Midwest did an interview with a local newspaper about her findings. She did not get an opportunity to review the reporter’s article before it was printed. When the article appeared, it contained disparaging and factually inaccurate comments about the tribe’s cultural traditions and how they allegedly contributed to the Indians’ health problems.
In addition, much of the research that has been conducted with Indian populations has tended to put too much emphasis on the “culture of poverty” in tribal communities. By focusing on the effects of poverty on Indian peoples’ way of life, many researchers have overlooked the strengths of the Indian community. As a result, a growing number of tribes are insisting that researchers focus on tribal and cultural strengths instead of on health deficits.
For instance, many studies have been conducted about the breakdown of American Indian families but very few have explored the positive aspects of Indian family life. One notable exception was a recent study on Indian parenting in which the researcher described how Indian mothers parented in such a way that the harmony (natural development) of their children’s lives was promoted through passive forbearance (the Indian pattern of care).
The Indian mothers did not parent in a way that controlled their children’s development but rather in a way that enhanced natural development through unobtrusive, respectful behaviors like listening, observing and being an example to others. In other words, the researcher chose to focus on the cultural patterns of parenting instead of on how poverty impacted the parenting.
Because of these kinds of experiences, tribes that participate in research studies want more of a say into the interpretation and dissemination of the findings. A researcher may need to include the tribe in the analysis of the data and get tribal approval for publication of the findings. This kind of tribal involvement can be written into the research proposal.
Finally, many Indian communities have become more “research-savvy” in order to better protect their interests. Many tribes now have their own Institutional Review Boards (IRBs) to which potential researchers must submit their proposals. Nurses who wish to do research in a particular Indian community need to become familiar with the appropriate procedure for obtaining the tribe’s permission to conduct the project. You may need to not only get the tribal IRB’s approval for human subjects but also get approval from either the tribal chief or tribal council.
In one research study conducted with a Southwestern tribe, the researcher had to first get approval from two tribal subcommittees and then go before the 15-member tribal council before approval for the project was given. The entire approval process required five visits with the tribe, and it took six months before the final decision was made.
Sometimes tribes will “barter” with researchers to ensure that both sides benefit equally from the partnership. For example, members of one small tribe in the Deep South successfully negotiated an arrangement in which the researcher agreed to assist them in writing an economic development grant in exchange for their participation in the study.
Playing by the (Cultural) Rules
In summary, nurse researchers must remember two important ethical principles when conducting studies in American Indian communities. The first is right to informed consent. The tribe needs to know the purpose of the research, who will benefit from the research, and how the research will be conducted with appropriate tribal input.
The second principle is do no harm. The researcher has an ethical duty to protect the tribal community by not violating cultural norms, by not publishing findings without approval from the tribe and by taking measures to protect the Indians’ culture. By following these rules of cultural sensitivity and respect, nurse scientists will greatly increase their chances of successfully overcoming the challenges of conducting much-needed research on American Indian health disparities.
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.”