Spring is the season of new life, even rebirth. It’s a fitting time for graduation ceremonies to be held, as young professionals embark on new careers that had previously been half-lived in textbooks and lectures.
Soon, thousands of members of the Class of 2012 will be flooding into the “real world” to join the team on hospital floors, in emergency clinics, and at countless other nursing facilities. Here, you’ll meet four soon-to-be members of the nursing work force, as they share the experiences that led them to their field, their hard-won advice for future students, and what they believe will keep them in nursing for the long haul.
Breanne Cisneros, R.N.
“People like you don’t go to schools like these.” That’s what Breanne Cisneros heard when she showed someone the list of colleges and universities to which she hoped to apply. “I was shocked,” Cisneros says. “Even though I was a low-income, Hispanic American female who had attended impacted public schools in the under-served city of Anaheim, California, I applied to top-tier institutions.” She eventually was offered admission and a full scholarship to Johns Hopkins University in Baltimore, Maryland.
Now, Cisneros is in the Master’s Entry Program in Nursing (MEPN) at the University of California, San Francisco (UCSF). She became an RN in 2010, and she is pursuing a master’s in critical care/trauma nursing. She hopes to become a critical care clinical nurse specialist. Cisneros says she “dreamed of working in health care” as a child, largely due to growing up with a disabled younger brother.
At Johns Hopkins, studying psychology, Cisneros says she “quickly learned [that person] was right—people like me don’t go to schools like that. Having come from a completely different socioeconomic background than my peers, and having very few shared experiences, I was isolated.” Not only that, she found her ambitions shaken during her academically challenging undergraduate years. “I lost faith in my abilities, and temporarily gave up on my dream,” she says. But her school and life focus shifted during her junior year at Hopkins, when her father sustained a traumatic brain injury (TBI) due to violent crime that left him permanently disabled. “This multifaceted tragedy changed my outlook and approach to life, resulting in a shift of priorities. It renewed my dedication to health care and motivated me to reach out to gain the academic skills I needed for success,” she says. “The RNs and Advanced Practiced Nurses provided warm, competent, patient-centered care that allowed my father and our family to heal. It opened my eyes to the world of nursing and changed my career and life trajectories.”
As a social work assistant in oncology at the Johns Hopkins Hospital and as an EMT-B in Baltimore, Cisneros “saw great socioeconomic disparities and their impact on health and access to care,” she says. “I recognized that my background was a unique tool that would allow me to help people who are scared, do not have adequate resources, feel isolated, and who do not understand the health care system or what is happening to their bodies. The Hispanic population is particularly vulnerable and subject to trauma, which I experienced firsthand.”
After graduating, Cisneros fulfilled her nursing prerequisites in a post-baccalaureate program at Tufts University in Medford, Massachusetts. “My educational journey has been just that: a journey,” she says. “I have struggled and faced many obstacles because of my background and socioeconomic status. However, support from the National Association of Hispanic Nurses, the Kaiser Permanente Latino Association, the Hispanic Association of Colleges and Universities, and the UCSF Nursing Alumni Association has helped me tremendously in achieving my goals and working towards my dreams.”
As an undergrad at the famously “physician-dominated” Johns Hopkins, Cisneros says she developed a “passion for interprofessional health care education.” She was the first nursing student to receive a fellowship to participate in the UCSF School of Medicine’s Curriculum Ambassador’s program, and she was the only nurse on the six-member team of interprofessional students. Together they developed and facilitated a nationally recognized, “revolutionary, school-wide, student-driven, student-centered interprofessional health care education curriculum for 500 students across the five health professions programs at UCSF,” she says. “Increased patient safety requires interprofessional collaboration, which is now critical given rising health care costs, an aging population, and physician shortages.” Cisneros and her team will continue to study the impact of interprofessional learning on collaboration, she says. She applies the skills developed in this program as a student representative on the Interprofessional Healthcare Education Task Force at UCSF as well, where she works with deans and other faculty members.
Among her other extracurricular activities, Cisneros is one of five MEPN students serving a fellowship as a Clinical Scholar at the UCSF Medical Center, where she contributes to the Medication Administration Accuracy Project (MAAP) in Nursing Performance Improvement. “The goals of the MAAP project are to standardize the medication administration process and eliminate nursing medication errors,” Cisneros says. “The vision is to establish best practices so that every patient receives safe, excellent quality care.” This experience led Cisneros to becoming the first nurse to complete a School of Medicine Pathway to Discovery certificate in Health Systems and Leadership, a career development program with a leadership focus.
After committing herself to these organizations, it’s no surprise Cisneros is passionate about leadership. Her most recent leading role? Studying the 24-hour survival rates for VT/VF (Ventricular Tachycardia/Ventricular Fibrillation) arrest at the San Francisco Department of Veterans Affairs, working on a quality improvement project studying early chest compressions and defibrillation within two minutes of cardiac arrest. “The best strategies are unclear for hospital implementation of early defibrillation programs,” she says. “In-hospital cardiac arrest is a major public health issue, and both the American Heart Association and the American College of Cardiology recognize the importance of early resuscitative care.” Cisneros and her team explored the feasibility of a two-minute defibrillation standard for monitored units to identify best practices as well as barriers to successful early defibrillation in cardiac arrest, among other things. The American Heart Association published the abstract and accepted it for their 2011 national meeting; Cisneros went there to present those findings. “This was an incredible opportunity to conduct scholarly work and present it at a national level,” she says.
Cisneros shows no signs of slowing down. And after the challenges of her not-so-distant youth, she intends to give back to those facing similar difficulties. “I plan to be a role model and make changes to the system that will help recruit, retain, and to encourage further professional and academic development of underserved students like myself,” she says. “My contributions towards the well-being of individuals are limited unless I can pass my knowledge onto others.” To that end, she hopes to earn her Ph.D. in nursing, and she is already an early advocate for the degree. “A Ph.D. is invaluable for improving patient care, contributing to research, informing health policy, improving the nursing practice, and developing the profession,” Cisneros says. “As a Hispanic nurse, I would add to faculty diversity and help to create a healthy culture in the learning environment.” However, Cisneros says those days are still far away; she intends to develop her skills at the bedside first and let that knowledge inform her doctoral studies.
“Through advocacy, outreach, and strong professional organizational involvement, I plan to actively make changes and reach out to Hispanic nurses—to recruit them, to retain them, and to encourage further professional and academic development,” Cisneros says. “I feel a responsibility to communicate my future clinical, educational, and research findings to my colleagues. As a nurse, I not only plan to meet the needs of my patients, but also meet the needs of my colleagues, Hispanic nurses. I believe that we must be involved in nursing at the local, state, and national levels in order to impact health policy and improve health care for Hispanics, and gain visibility and recognition as professionals so that we can influence and facilitate such change.”
Even as a child in Nigeria, Musiliu Ogunbayo was acutely aware of the importance of health care and wellness. He applied that interest to the study of nursing, and he should graduate from the practical nursing program at The Salter School of Nursing and Allied Health in Manchester, New Hampshire, this spring. (He hopes to earn a bachelor’s degree in the future.) Ogunbayo’s career path was perhaps made more profound from early experiences with the tribal custom of tattooing.
“I am always proud of my cultural heritage,” Ogunbayo says. “We, the Yorubas, are known all over Nigeria and, indeed, the whole world for our tribal marks.” However, he did not receive the customary tattoos as an infant, due to his father’s absence at the time. After being ridiculed for his lack of tribal marks as a child, Ogunbayo finally, excitedly, went to have them done at the age of nine. This decision was also heavily influenced by his admiration of his school teacher and his tribal marks.
The tattoo incisions were made by a local baba, an elderly manwith experience administering the tattoos, using an old, rusty blade. Ogunbayo found himself in great pain following the procedure and for several days afterward, and he questioned his decision to have them done.
Upon returning to school, his teacher commented on the new tribal marks; Ogunbayo shared how the teacher himself had actually influenced his decision. The teacher’s surprising reply: he hated his own tribal marks. Having been done as an infant, he had no choice in the matter and now had to live with them. This led Ogunbayo to consider his own tattoos, and he pondered the health risk he had taken just in having them done. “Sometimes, I sit and think, ‘what if the baba had used that knife on someone with HIV before using it on me?’ I also imagine what if bacteria from the knife or from the [dye] had entered my bloodstream, causing an ailment that could not be cured?”
After graduating, Ogunbayo intends to work in America to gain more experience, which he will then take back to Nigeria. “I feel like a lot has been given to me, so I chose nursing as a career because I want to be able to give back to my community someday,” Ogunbayo says, and he hopes to apply his nursing knowledge and create more awareness upon returning home. “I want to be able to contribute to a healthier environment where people are more cognitively aware of their health needs. I want to see a society where people would not have to wait till they get very sick before they go to see the doctor. I want to help build a society where people with medical needs are treated with fairness and respect.” He intends to open a clinic in his home country to provide high-quality, affordable health care.
To would-be nursing students, Ogunbayo does not shy away from the difficulties of the program: Cutting down on his work hours to make time to study has also cut into his income, causing a strain in finances. Socially, he has little time for friends or family. “The biggest of all is a cultural conflict,” Ogunbayo says. “I always find myself having to do something different from the way I was raised. But I finally understand that meeting my patients’ cultural and health needs is more important.”
And Ogunbayo sometimes finds being the only male in his class to be a challenge, but he credits his instructors and classmates for giving him a positive learning experience. “Make sure you choose a good school that meets your career goals, financial status, and lifestyle,” Ogunbayo says. And don’t forget: “Your instructors are your best resources; use them and see them as your mentor and not your judge.”
Despite its challenges, Ogunbayo maintains his passion for the field. “Nursing is a very rewarding profession,” Ogunbayo says. Even if the particular field or specialty a nurse pursues isn’t the most lucrative, such as treating impoverished peoples, “you will be happy for the differences you are making in people’s lives.”
Kelsey Sonnabend finds strength and meaning all in one quote: “To the world you may be one person, but to one person you may be the world.” She adopted this saying from her friend Kate, and she relies on it when her work and studies in Arizona State University’s (ASU) B.S.N. program become challenging. “This quote is what makes it all worth while in the end,” she says. “That one patient that you help that looks you in the eye and tells you how thankful they are that you are there helping them when they can not help themselves.”
A native of Gilbert, Arizona, Sonnabend’s family is from Rapid City, South Dakota. They are members of the Oglala Sioux tribe situated on the Pine Ridge Reservation, roughly 120 miles away. “I was raised so far from my reservation because my dad is a part of the commissioned corps and was placed in Phoenix, Arizona, to work,” Sonnabend says. “However, I remember spending my summers in South Dakota visiting my family and grandpa, Pahaska who, if you have ever been to Keystone, South Dakota, is the amazing Native American painter who many tourists took pictures with.”
Sonnabend is currently in her final semester at ASU, scheduled to graduate in May of this year. As a high school student, she says she couldn’t decide what to study in college—but she did know she wanted to impact others in her work. “I knew there was many different ways I could do this, either through politics or business,” she says. “Then I remembered my mom.” Also a nurse, her mother would share work stories with Sonnabend and her brother. “I remember listening to her stories and how much people appreciated what she would do for them.”
But as the years went by, different factors colored Sonnabend’s desire to become a nurse. The first was her determination to prove naysayers wrong. Second in time, but perhaps more importantly, Sonnabend became friends with a fellow nursing student, the aforementioned Kate. “We took many classes together and went through many grueling nights of studying, editing each other’s papers, and the stress of applying for the program together,” she says. In the spring of 2009, Kate grew ill, her health declining quickly and impacting her school work.
“Kate had many strange symptoms of many things and saw many doctors,” Sonnabend says. “When the semester ended I remember eating a grilled cheese sandwich with her and her telling me a doctor told her it was a severe sinus infection and she was headed home to Washington to get it all fixed up and she would see me in the fall for our first semester of nursing school. Two days later I got a call that she had passed away. That completely changed my world. Everything was different; to truly see how fragile life is was so shocking for me. I then at that point made the decision that no one should have to go from doctor to doctor in pain and fear. I wanted to be that nurse who would be more caring, loving, and support my patients.” Talking with Katie’s parents after her passing only solidified Sonnabend’s resolve. “What initially inspired me to be a nurse was the amazing, caring, and courageous stories of my mom,” she says. “What changed the kind of nurse I would be and re-kindled the want to be a nurse was the death and life of my friend Kate.”
Sonnabend hopes to use her nursing degree wherever she is needed, she says, whether that’s a well-known hospital in Phoenix, a third-world country, or another underserved area. She also wants to earn her master’s and doctoral degrees to further her abilities to help those in need.
“Walking into this program, there are a lot of stresses, such as the need to have a high GPA, competing against many other highly qualified students, and spending four years of your life strictly focused on studying and school,” Sonnabend says. She remembers being warned during the first week of school: even if you get into the “impossible” nursing program, you probably won’t graduate on time. Right on schedule, four years later, Sonnabend is ready to enter the nursing workforce.
Though she admits she found her studies challenging—“it does take a lot of self-discipline and sacrifice,” she says—in Sonnabend’s young life, she has found this much to be true: when you’re passionate and committed to becoming a nurse, nothing can stop you. Even those that might falter along the way can push themselves to achieve their goals. To the generations of nurses to come after her, she has this to say: “You have the ability to do anything another human has done.” Even if you sometimes struggle academically, “this simply means you just have to put a little more time in figuring out the way you learn best,” she continues. “Do not listen to everyone around telling you that you aren’t smart enough or that nursing is not a good field, because if this is what you want you shouldn’t let those things get to you. If you work hard and you keep in contact with your school advisors and professors, you will get far. It is a difficult program but it really will be worth it when you finally get to walk across that stage and call yourself an RN.”
David Allen didn’t always want to be a nurse. He did know, however, that he had a passion for medicine in a broad sort of way. Growing up in the Boston suburb of Natick, Allen was a “pretty big athlete,” and he developed an interest in muscles, body movement, and his own physical therapy and sports-related injuries. Allen says he spent a good deal of time in the ER and even negotiated with his orthopedic doctors. He’ll be graduating in May of this year with a B.S.N. from the University of Pennsylvania School of Nursing.
“I’ve always been really interested in emergency medicine,” Allen says. At 16 years old, he wanted to be an EMT. He took a wilderness first responder exam to get involved in outdoor recreation, and his adventurous spirit endures. “My dream job would be a flight nurse, which I know isn’t that original for a guy!” he says with a laugh.
The decision to study nursing came after the decision to attend UPenn, as the school simply “grabbed” Allen and met his overarching undergrad goals. A brief informational meeting with UPenn’s admission office introduced him to nursing, particularly the role of nurse practitioner, which he says he had never really heard of. It too clicked with him, as he realized it would allow him to do all the things that interested him.
Allen says it took a few years for him to really appreciate nursing and the ability to work one-on-one with patients. Now, he says he can fully articulate why he is happy with his choice to become a nurse.
Allen says his classmates are brilliant and highly motivated. “Everyone’s working to be the top in what they’re doing.” Yet, though his nursing class only started with about 10 males, several have dropped out, as did a number of nursing students in general. Given the trying nature of the first years of the nursing program, this didn’t surprise him. “It can feel subservient, especially in some of the basic classes,” he says. “You grow to appreciate the role nurses play in patient care—which is why we’re all here.” Allen says he believes the work will become more fluid, second nature, and perhaps easier as years go on and he gains more experience. “I think I’ve been really lucky,” Allen says. “UPenn does a really great job in supporting students.”
True to his past and his flight nurse dreams of the future, Allen says he enjoys the fast-paced nature of the emergency department, and he hopes to work in a similar trauma-based environment.
The challenges may scare would-be nurses, particularly those graduating from high school in this economically uncertain time, a world where nurses are desperately needed to fill current and projected future vacancies. But Allen offers some sage advice: “Really think about what you value and what you want to do, and then talk to people in other fields” to see if your vision of the future and the reality align, he says.
After enrolling in the program, know that it will be difficult. If you find you don’t love nursing, Allen says, give it a chance, talk to more people, and try to determine if what you don’t like is really indicative of nursing or if it might change as time goes by. Perhaps then you, like Allen, will find the rewards far outweigh the challenges.
The Indian Health Service (IHS) and the National Institutes of Health (NIH), both agencies of the Department of Health and Human Services, recently agreed to continue their partnership initiative to include American Indians and Alaskan Natives (AIs/ANs) as participants in and beneficiaries of the research and training supported by the NIH.
Shortly after, the IHS and the National Institute of General Medical Sciences (NIGMS), one of the NIH Institutes, announced that they are the recipients of approximately $3 million in grant funds to support AI/AN medical research efforts.
Eight Native American Research Centers for Health (NARCH) programs have been selected to receive grants for proposals submitted during fiscal year 2001: the Northwest Portland Area Health Board, the Alaska Native Tribal Health Consortium, the Inter Tribal Council of Arizona American Indian Research Center for Health, the Five Civilized Tribes, the Black Hills Center for American Indian Health, the White Mountain Apache Tribe, the New Mexico Tribal Healthcare Alliance and the California Indian Health Council.
“These grants are critically important in our efforts to improve the health status of [Native Americans],” says HHS Secretary Tommy G. Thompson. “These funds will help address the underrepresentation of AI/AN researchers and their perspectives in medical research, and will empower tribes to influence research projects relevant to Indian communities.”
“These funds will increase the capacity of tribes and universities to work in partnership to reverse a trend of Indian communities frequently being the subject of research and not benefiting from that research,” adds Michael H. Trujillo, MD, MPH, MS, director of the IHS. “Additional benefits from the NARCH program will be culturally sensitive research, research influenced and sanctioned by tribal communities, and the encouragement of AI/AN youth to consider research, science and public service as career options.”
In related news, the IHS recently relocated its headquarters functions to 801 Thompson Avenue in Rockville, Md. after residing at the Parklawn Building in Rockville for the past 31 years. The new IHS headquarters building is newly renovated and contains 50,918 square feet. This headquarters will house all of the Office of the Director functions and most of the programs of the Office of Public Health and the Office of Management Support.
“This building represents a commitment to improve the effectiveness and efficiency of the IHS headquarters staff in support of our mission to provide the highest quality health care services to Indian people,” says Trujillo.
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.”
For More InformationFor general information about career opportunities in the Indian Health Service:
www.ihs.gov To view current IHS job listings:
www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/Index.cfmFor information about the U.S. Public Health Service Commissioned Corps:
www.usphs.govFor information about the IHS Loan Repayment Program:
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.”
Although a small but growing number of programs now exist to prepare minority nurses for leadership roles in health care management, academia and health policy-making, very few–if any–have focused specifically on American Indian and Alaska Native nurses. But that is about to change with the arrival of Pathways to Leadership, an Indian Nurse Leadership curriculum that has been in development for several years.
The project began in June 1997, when a team of four Indian nurse leaders and one non-Indian nurse leader were selected to attend the Third Congress of Minority Nurses in Denver, which was sponsored by the Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing. From this conference, the plan to create a leadership development program tailored exclusively to the needs of Indian nurses emerged.
Initially, the proposed curriculum focused on generic leadership behaviors and skills that are not specific to Indian culture. However, the Indian team members identified the need to explore the concept of Indian nurse leadership further and to identify whether the dimensions of the Indian leadership style were different from those of general, mainstream leadership. To help define Indian nurse leadership, the National Alaska Native American Indian Nurses Association (NANAINA) was instrumental in supporting and encouraging the development of three Indian Nurse Leadership modules for the curriculum, along with a model showing the relationship of the different concepts examined in the modules.
As a result, the present Pathways curriculum consists of nine modules. Six of them focus on general nurse leadership topics:
Personal and Professional Communication and Mentoring
Being a Futurist.
They are complemented by three culturally competent modules devoted to the following topics: Being a Leader in the Indian Way, Indian Nursing and Tribal Sovereignty, and Indian Nursing and Indian Health Programs.
The focus of the general leadership curriculum is on personal development of leadership. Native Americans value personal growth and self-actualization, so emphasizing a personal perspective of leadership is compatible with Indian culture and values. In addition, Indian concepts are interlaced appropriately within the generic leadership modules. The two worldviews are compared and contrasted. This provides the Indian nurse with a more bicultural view of Indian and non-Indian health care systems.
Filling a Knowledge Gap
One of our biggest challenges in developing the Indian-specific topics was that knowledge about the concept of Indian nurse leadership is almost nonexistent. A review of the literature revealed limited research in the area. To fill the void, we utilized several sources of information to help us develop the curriculum. These included interviews with Indian leaders, conferences on Indian leadership, historical information on Indian leaders, personal experiences of the team members, directors of Indian health programs, and focus groups with Indian nurses and non-Indian nurses who worked with Indian patients. We also explored the spiritual, traditional and ceremonial Indian ways of knowing.
Armed with these data and insights, we developed the Indian section of the Pathways curriculum. Module 7, Being a Leader in the Indian Way, identifies the facets of Indian nursing and the characteristics and actions of Indian nurse leaders. It presents and explores concepts of Indian nurse leadership such as spirituality, humility and self-actualization. Module 8 focuses on political issues relating to Indian tribes and nations, including tribal sovereignty, self-governance and the application of these concepts to Indian nurse leadership. It also examines the importance of being a spiritual leader.
The last module, Indian Nursing and Indian Health Programs, explores Indian health issues, Indian health ethics and Indian tribal programs. Information from the generic leadership modules is interwoven with the Indian concepts to synergize the nine modules into a complete leadership training program suitable for developing the skills of current and future Native nurse leaders.
Putting All the Pieces in Place
In fall 2002 at the eighth annual NANAINA Summit in Oklahoma City, the Pathways team presented the proposed leadership curriculum to Indian and non-Indian nurses for their evaluation and recommendations. This peer review enabled us to identify gaps in the curriculum. It also helped us realize that we needed to have a framework to guide us in what the curriculum should include and how it should be taught. To build this guiding framework, we again drew information from a variety of sources. We used data that had been gathered from focus groups of Indian nurse leaders several years earlier at NANAINA Summit IV. We also examined the models of Indian nursing developed by NANAINA members Roxanne Struthers, Sandy Littlejohn and John Lowe.1, 2 Their work provided a valuable starting point for creating our model framework.
The guiding framework for Pathways to Leadership–which encompasses both the Indian and generic leadership modules–is based on three themes:
Point of reference (being connected) for the Indian nurse leader. Connectedness for the leader focuses on the individual, the family and the tribal community.
What an Indian nurse is. Native nurses can be defined by such terms as: spiritual, self-actualized, visionary, quiet presence, humble, wise, experienced, political and recognized.
What an Indian nurse leader does. This includes mentoring, serving as a role model, communicating, listening, mobilizing, inspiring and demonstrating values.
Putting It into Practice
Now that the final stage of developing the Pathways to Leadership curriculum was finished, it was time to “take the show on the road.” In June 2003 the Pathways team organized a gathering for Indian nurse leaders in Phoenix, Ariz., to present the new leadership training curriculum. Two other nurses collaborated with us in implementing this event: the nurse consultant for the Phoenix area of the Indian Health Service, and the director of Arizona State University College of Nursing’s American Indian Students United for Nursing (ASUN) project.
Seventeen Indian nurses attended the weeklong gathering. We presented the curriculum modules over the week at the rate of two per day. Each day began with a prayer or meditation by an Indian elder, followed by opening circles in which all the participants sat together in a circle to share our thoughts and ideas. The Indian cultural tradition of the circle is important, because it means that we will come back to the beginning.
Several guest speakers were invited, to serve as examples of leadership and express their views of leadership in relation to the concepts discussed in the modules. For example, one former tribal chief described his three principles of leadership: “be honest to yourself,” “listen to people” and “respect their culture.” One of the Pathways team members served a meal at her home for all of the participants. At the end of the week, the gathering ended with a giveaway (a Cherokee tradition of expressing gratitude). We gave gifts to the participants to show our appreciation to them for attending and for letting us be their teachers. Finally, an ending circle was formed and the closing ceremony was conducted by an Apache healer.
Participants were asked to evaluate the program daily, with a summary evaluation at the end of the gathering. This feedback revealed that the curriculum was well received by the students.
While we are proud of this initial success, at this point Pathways to Leadership is still an ongoing work in progress. The presentation in Phoenix was a pilot project that we hope will set the stage for nationwide implementation. Our goal is to continue to refine the curriculum for expanded use in schools of nursing and with nursing leaders of tribal health programs. For more information about the Pathways to Leadership project, please contact Lee Anne Nichols ([email protected]), Martha Baker ([email protected]) or Judy Goforth Parker ([email protected]).
Lowe, J. and Struthers, R. (2001). “Profession and Society: Conceptual Framework of Nursing in Native American Culture.” Journal of Nursing Scholarship, Vol. 3, No. 3.
Struthers, R. and Littlejohn, S. (1999). “The Essence of Native American Nursing.” Journal of Transcultural Nursing, Vol. 10, No. 2.
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.