Healing a Wounded Past

Healing a Wounded Past

“Just being born American Indian brought me into the legacy of harm and poor health,” asserts Roxanne Struthers, RN, PhD, CTN, assistant professor at the University of Minnesota School of Nursing in Minneapolis and president-elect of the National Alaska Native American Indian Nurses Association (NANAINA). “I have seen in my family the effects of disease–TB and other epidemics with no resistance and little or no treatment. And not only disease [but also cultural loss]. My mother’s first language was Ojibwe; she was beaten when she spoke it, then her only language, at a rural reservation school. Later, she would not allow us to speak it at home. Now as a nurse, all the diseases I encounter every day [in Indian patients]–alcoholism, drug dependence, diabetes, overeating–I see as parallel to my own life. Some younger nurses may not be as aware of this at first, but it will resonate when they hear the history.”

“That’s when I started to see–and later I started to hear more,” recollects Lillian Rice, a Forest County Potawotami Tribe Native practitioner and alcohol/drug counselor, born in backwoods Star Lake, Wisc., and now living in Minneapolis. Then only 17 years old (in 1949), she linked the negative behavior of a close family member sinking into alcoholism with what she had heard earlier as a child from her grandmother. The grandmother had told of TB epidemics and children’s deaths, of scarlet fever quarantining with confiscation of Native ceremonial paraphernalia, of relocation without treatment or recompense, of going back home and finding the old estate burnt down by the U.S. government. Other family members brought forth painful memories from boarding school days of horsewhipping and humiliation.

“That’s when I decided to become a healer,” says Rice, who leads women’s sweat lodges and women’s spiritual gatherings. “After raising my five children and getting into chemical dependency work, I made a decision with a promise to the Great Spirit to be there for [Indian] women in honor of my grandmother.”

Lea Warrington, RN, BSN, gives a presentation on historical trauma to nursing students at the University of Wisconsin-Milwaukee.Lea Warrington, RN, BSN, gives a presentation on historical trauma to nursing students at the University of Wisconsin-Milwaukee.

“If you are Native and born into a Native family, your community’s past is a part of who you are,” attests John Lowe, RN, PhD, a faculty member at Florida Atlantic University’s College of Nursing in Boca Raton and a researcher/designer of Native American teen interventions to prevent and reverse substance abuse and reduce HIV/AIDS risk. “I was raised in a Cherokee farming community in the Southeast and went to school there,” he says. “My father, now 80, would have had to go to boarding school, so he didn’t go to any school. He was needed on the farm and his parents did not want their kids taken away. [I used to wonder,] why didn’t my father have the problems we see so often [in Indian communities], such as alcoholism and diabetes? Why was he OK? When I went away to attend a college nursing program in the 1970s, I took with me that vision of my father. He knew who he was: Cherokee, with traditions, values and beliefs. He faced many barriers, but something within him was very grounded and centered, and that kept him OK. If we [as nurses] could understand it, that is what we should promote.”

These Native American health practitioners are describing historical trauma. Although of recent coinage as a term, its devastating effects on the physical and mental health of American Indians and Alaska Natives have been documented for decades. Native healers, with their feeling for root causes, have tapped traditional spiritual resources to help put their families and communities back on a path to recovery. Now, working right in the mainstream of Western health science, leading Indian health professionals and researchers have given the concept a scientific name and a place for testing in their disciplines. The literature is now packed with empirical clinical evidence and qualitative data. Promising new models of care are emerging.

And today at the front lines, strategically positioned to put these models into practice, are Indian nurses. Their recognition of who they are and what they do has inspired a call to action for Native nurses: to recognize the critical role they can play in helping their people begin the process of healing from the harms of historical trauma.

Connecting, Listening, Empowering

John Lowe, RN, PhDJohn Lowe, RN, PhD

How does the healing start? For Native nurses, it begins with knowing yourself, your community and your common past.

“First, heal yourself,” urges Struthers. “The healing of one is the healing of all. Then you can share [with patients]. It does ripple out. You can reassure your patients by saying, ‘You are not unusual, you are not alone.’ History lessons are OK, too.”

Rachel Wright, RN, BSN, a master’s student in the nurse practitioner program at the University of Oklahoma College of Nursing in Oklahoma City, talks in terms of empowering patients.

“In fact, I think that’s the main thing nurses can do,” says Wright, whose father is Cherokee. “I agree that I see many Native American patients with social problems associated with physiological problems, but I believe that some of those are related to the self-esteem issue, lack of knowledge and lack of confidence to make lifestyle/behavioral changes that impact their health status. Any patient who feels like a failure and does not understand the problem most likely will not comply with the treatment plan. The nurse or nurse practitioner must help patients learn appropriate knowledge and skills to help themselves.”

To get compliance and accurate information from your patients, make sure the communication connection is two way, advises Lea Warrington, RN, BSN, manager of the Gerald L. Ignace Indian Health Center, an urban Indian Health Service facility in Milwaukee. Warrington, who is of Menominee Indian heritage and visits the reservation frequently, often finds out what’s really going on with her patients–as opposed to what’s in the clinic record–when she encounters them on their own “turf.”

Communication failure may come from passivity or not wanting to cause conflict, Warrington warns. Take the case of a 72-year-old patient whose daughter found all his medication bottles unopened in his medicine cabinet. The patient’s record at the clinic showed that he had very literally answered “yes” when asked whether he had filled his prescriptions and “no” as to whether he “had any problems with them.”

Often, after patients leave the facility, Warrington hears complaints about the way the clinic works, or about problems with service, that never showed up on the returned patient satisfaction surveys (usually checked off as “excellent”). “Outside the clinic, even though I work there, patients open up because we are in our own common setting, such as the elderly center, the school or on the street,” she explains.

Native nurses who work within the mainstream Western health care system face a paradoxical challenge, Warrington adds. “I believe that Native patients appreciate that Natives work in health care centers,” she says. “But I think, though, that sometimes we end up having to prove that we can provide as good service as non-Natives. It’s an odd situation to be in, because of the way Native people perceive the overall health care system as not being Native-friendly.”

Reducing Suicide Risks

“Start off with questions checking for traditionality and family connectedness,” suggests Dan Edwards, DSW, director of the University of Utah School of Social Work and Native American Studies in Salt Lake City. This information is essential for effective assessment, particularly in the mental health area, such as evaluating suicide risk.

Three first questions, suggests Edwards, might be: Where do you live? Do you know the [tribal] language? Have you ever been to your own tribal ceremonies? (For example, a female patient could be asked, “Have you ever been to a kinaalda [a Navajo coming-of-age ceremony for girls]?”) Then, he says, “as you establish rapport and if the patient seems open to it, you can begin talking about spirituality and religion.”


Edwards is of Yurok heritage, with pre-1970s personal experience with foster care, adoption, boarding schools and assimilation pressures. He has observed the links for bad parenting and high divorce rates, heavy drinking patterns, vulnerability to negative peer pressures and suicide clusters.

Alaska Natives and American Indians rank first among all ethnic groups in suicide rates. While the particulars vary for subgroups–e.g., Indian people living in cities versus rural areas and reservations–the causes can be traced to historical trauma.

“The lost birds–Native Americans who were adopted out or in foster care and have completely lost their culture–are at high risk for suicide and/or risk-taking behavior if they have not successfully taken on their new family’s ways to a level of comfort that will offset these problems or if they have not sought their own culture later in life,” explains Margaret P. Moss, RN, DSN, assistant professor at the University of Minnesota School of Nursing and a Native Investigator (Hidatsa/Lakota background) in research.

Getting the complete family and lifestyle picture is also critical for suicide prevention in Indian teens and young adults, a particularly high-risk group, adds Faye Annette Gary, RN, EdD, the Medical Mutual of Ohio Professor of Nursing for Vulnerable and At-Risk Populations at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland.

Gary, who gave a presentation on Native adolescent health and preventive education at NANAINA’s ninth annual Summit in Park City, Utah, last September, urges Native nurses to recognize the profile: male, between 15 and 24; single; likely to be under the influence of alcohol before suicide attempt; lived with a number of ineffective/inappropriate parental substitutes. Familiar historical trauma issues include “once a resident in boarding schools with frequent moves,” “in confinement centers at early age” and “experienced a loss of a significant other through violence.”

Healing Through Reconnecting

To get ideas for meeting the toughest health care challenges, such as diabetes, periodically review the Native American nursing literature–especially the articles published by Struthers, Lowe and other Native nurse researchers as part of the ongoing Nursing in Native American Culture project (see “References” and “The Conceptual Framework of Nursing in Native American Culture” sidebar).

Diabetes, suggests Struthers, can be looked at in a current community context along with a racial memory of the past–the taking of Indians’ land, with no more hunting and fishing; forced relocation interfering with diet and exercise; and the poor food choices that come with poverty.

Talking circles–community sharing groups based on Indian tradition–are being tried in many places to help patients deal with diabetes self-management and emotions. In two circles (for diabetes and domestic violence) at the urban clinic where Warrington works, patients learn to listen as well as talk, taking turns with “the talking stick.” The groups start by smoking cedar or sage in a shell (sometimes called smudging), which has a calming effect, and then close down the circle the same way.

Lowe offers a scenario, summarized below, showing how the conceptual nursing framework’s connectedness dimension might work for an Indian patient with diabetes:

► The nurse listens to a patient describe how he has been managing his diabetes. She is seated next to him about one foot away. There may be long periods of silence, but the nurse appears comfortable and does not ask demanding or threatening questions.

► Conversation ensues, centered around who the patient’s family members are and his everyday life and activities. The nurse talks about the community the patient lives in and resources available.

► As the patient talks about the foods he eats, the nurse does not act condescending in her reply about foods he should be avoiding. Instead, she talks about alternatives and options available to the patient. The nurse knows that family and community must be involved and that the patient may need to be encouraged to use them as a resource and to allow them to help him.

► The nurse remains nonjudgmental by respecting what the patient shares. He is encouraged to talk and holistically express who he is in his everyday life and activities, his beliefs, his strengths, his management of his diabetes, and who he is connected to, such as family, community and other elements of the creation/universe. There may be storytelling and the nurse may share similar experiences.

► Native American nurses sometimes connect at a deep indigenous “oneness” level when caring for another Native American, especially in talking about how the past, present and future have affected them in similar ways.3

And finally, for a tested model of customizing interventions for a specific tribe, review Lowe’s ongoing work on Cherokee self-reliance and its application to substance abuse and other nursing interventions for teens.4 On a lifelong quest to understand what kept his own Cherokee father “OK” in the midst of cultural devastation, Lowe has analyzed the historical trauma dealt repeatedly to Cherokee men and the misguided policies and health concepts imposing non-Cherokee notions of independence.

Revealing the true Cherokee conception of self-reliance, which rests on being responsible, being disciplined and being confident, has produced a model that will work for holistic nursing assessment of Cherokee patients. Promotion of the core Cherokee value of interdependence promises to help overcome many of the ills that have come from disconnection and non-Native concepts of self.


1. Struthers, R. and Littlejohn, S. (1999). “The Essence of Native American Nursing.” Journal of Transcultural Nursing, Vol. 10, No. 2, pp. 131-35.

2. Lowe, J. and Struthers, R. (2001). “A Conceptual Framework of Nursing in Native American Culture.” Journal of Nursing Scholarship, Vol. 33, No. 3, pp. 279-83.

3. Lowe, J. (2002). “Balance and Harmony Through Connectedness: The Intentionality of Native American Nurses.” Holistic Nursing Practice, Vol. 16, No. 4, pp. 4-11.

4. Lowe, J. (2002). “Cherokee Self-Reliance.” Journal of Transcultural Nursing, Vol. 13, No. 4, pp. 287-95.

5. Struthers, R. and Lowe, J. (2003). “Nursing in the Native American Culture and Historical Trauma.” Issues in Mental Health Nursing, Vol. 24, No. 3, pp. 257-72.

Mentors to the Max

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

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

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

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

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

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

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

Whatever It Takes

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

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

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

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

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

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

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

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


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

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

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

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

Traditional Beliefs, Modern Technology

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

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

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

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

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

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

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

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

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

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

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

Remarkable Results

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

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

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

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

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

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

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

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

A Master Plan for Mentoring

By Pam Chwedyk

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

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

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

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

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

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

Leveling the Playing Field for Tribal Colleges

Nursing programs at Tribal Colleges and Universities (TCUs)–such as the Nursing Departments of Oglala Lakota College in Pine Ridge, S.D., Sisseton Wahpeton Community College in Sisseton, S.D., and Salish Kootenai College in Pablo, Mont.–play a tremendously key role in helping American Indian students in underserved areas increase their access to nursing careers. Yet many of the nation’s 32 TCUs are underbudgeted, receive no state funding and are struggling to meet their operating costs.



Recognizing, as U.S. Secretary of Education Rod Paige puts it, that “the nation’s TCUs have an historic and unique role in American higher education and serve many Americans who might otherwise be left behind,” the federal government has expanded and strengthened its commitment to supporting these important institutions. As part of the ongoing White House Initiative on Tribal Colleges and Universities (WHITCU), President Bush issued an executive order on July 3 creating a President’s Board of Advisors on TCUs within the Department of Education.


Chaired by Ron McNeil, president of Sitting Bull College in Fort Yates, N.D., and a member of the Standing Rock Sioux tribe, the advisory board is charged with ensuring that TCUs have full access to federal and private programs and funds that benefit other higher education institutions. Specifically, the group will make recommendations about ways the federal government and the private sector can help tribal colleges expand their resources, programs, facilities and use of technologies. The board’s 14 members, most of whom are American Indians, include several other TCU presidents as well as Indian leaders from the business, cultural and political arenas.

In addition, President Bush’s 2003 budget calls for more than $18 million for programs to strengthen Tribal Colleges and Universities–a 3.6% increase over current funding levels.

For more information, contact the WHITCU office in Washington at (202) 260-7485 or [email protected]. The WHITCU Web site is located at www.ed.gov/offices/OPE/TribalColleges.

Tribes Know Best

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.

Trust Responsibility

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

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.

Tribal Politics

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.

Working for the Indian Health Service

Did you know that within the United States of America there are several functioning governments? American Indian and Alaska Native (AI/AN) tribes possess a nation-within-a-nation status, meaning that the U.S. Constitution recognizes American Indian and Alaska Native tribes as distinct governments. There are more than 560 federally recognized tribes in the U.S. , and the nation’s estimated 2.6 million members live mainly, but not exclusively, on reservations and in rural communities in 35 states.

Unfortunately, the AI/AN people have experienced a lower health status in comparison with other Americans. Their lower life expectancy (almost six years less than the “all races” population expectancy) and the disproportionate disease burden (see the Mortality Rate Disparities chart for details) have been rooted in economic adversity and poor social conditions. There is an organization working to remedy the disparity.

Providing Health Services

The Indian Health Service (IHS), an agency within the Department of Health and Human Services, provides a comprehensive, health service delivery system to approximately 60% of the AI/AN population living in the United States . Their stated 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.” To that end, the IHS actively assists tribes in developing their health programs.

AI/AN people now have access to health care services in 49 hospitals and over 500 other facilities. A combination of U.S. federal funds allocated to the IHS through the Snyder Act of 1921, Public Law 93-638 self-determination contracts, and more than 9,000 contracts between tribes and independent health care providers have made this possible.

The IHS ensures that preventive measures involving environmental, educational and outreach activities are combined with therapeutic measures into a single national health system. Within these broad categories are special initiatives in traditional medicine, elder care, women’s health, children and adolescents, injury prevention, domestic violence and child abuse, health care financing, state health care, sanitation facilities and oral health.

Career Opportunities Abound

With so many responsibilities, the IHS employs a large staff to meet the diverse needs of the American Indian and Alaska Native population they serve. The agency employs approximately 15,000 people, including members of virtually every discipline involved in providing health care and social and environmental health services. They currently have a vacancy rate of about 12% for health professionals, so there are many career opportunities available.

Individuals with health-related degrees can join the IHS as civil servants or as commissioned officers in the Public Health Service (PHS). All Indian Health Service jobs, along with some tribal and urban Indian health program positions, are listed on-line at the IHS Web site (www.ihs.gov) under the Job Vacancies Database link. Additional IHS jobs can be located through an on-line search at FedWorld Federal Jobs Search and USAJOBS.

Each vacancy listing on IHS’s Web site contains contact information for the position; get in touch with the person listed in order to apply. For most permanent positions, you must be a “status” candidate. Status candidates are Indian Preference eligibles, current permanent federal employees, reinstatement eligibles or applicants with special appointing authority. All IHS positions are subject to Indian Preference laws.

Education and Continuing Education Opportunities

The Indian Health Care Improvement Act, Public Law 94-437, authorizes the IHS to administer three interrelated scholarship programs to meet the health professional staffing needs of IHS and other health programs serving AI/AN people. The IHS also administers a Loan Repayment Program for the purpose of recruiting and retaining highly qualified health professionals to meet staffing needs.

The PHS Commissioned Officer Student Training Program and Extern Program provides students of the health professions the opportunity to gain experience in a health service environment during free periods of the academic year. The Indian Health Professions Program provides scholarships, loans and summer employment in return for agreements by students to serve in IHS, tribal or urban Indian programs. As a matter of law and policy, the IHS gives preference to qualified Indians in applicant selection and career development training. And the PHS National Health Service Corps offers scholarships to medical students who agree to enter primary care specialties and to sign on for a minimum two-year tour of duty in PHS programs, including IHS direct and tribal programs.

In a speech given at the Montana/Wyoming Tribal Leaders Council Meeting this past April, Charles W. Grimm, DDS, M.H.S.A, and interim director of the IHS asserted his personal goals and the spirit of the goals of the IHS. He states, “I am committed to raising the health status of American Indians and Alaska Natives—and it is not just about access to care, or just about improving the educational opportunities for our people, or establishing a safe community, or building homes. It is about all these things, and many more that are interdependent and necessary. One Aspect of well being builds on another. Each of these things requires all of these things.”