Baccalaureate Nursing in Rural Oklahoma: Strategies for Success

Baccalaureate Nursing in Rural Oklahoma: Strategies for Success

ECU@SOSU nursing students Karen Holiday, Dana Danderson, Sabrina Durant and Brandie Gray[email protected] nursing students Karen Holiday, Dana Danderson, Sabrina Durant and Brandie Gray participate in a clinical day at the Choctaw Nation Health Care Center in Talihina, Oklahoma.

Providing baccalaureate nursing education in a culturally diverse rural setting affords unique opportunities and challenges for faculty, administration and students–especially when that education is delivered via interactive television. This article will describe how East Central University (ECU) and Southeast Oklahoma State University (SOSU) joined resources to offer a distance learning extension of ECU’s baccalaureate nursing program at SOSU.


For more than 30 years, ECU has been the only baccalaureate nursing program serving southeastern Oklahoma and north Texas. Both ECU and SOSU are situated in southeast Oklahoma, which is home to the Chickasaw and Choctaw Nations’ tribal headquarters. ECU’s service area consists of 22 counties, 20 of which are federally designated as medically underserved. Approximately 35% of the university’s nursing majors self-identify as American Indian and a high percentage of nursing majors are first-generation college attendees. There is a higher percentage of American Indian students enrolled in nursing compared to the average percentage of American Indian students enrolled on both the ECU and SOSU campuses in other academic majors.

In the mid 1990s the Oklahoma State Regents for Higher Education urged academic institutions to work collaboratively to preclude program duplication. The presidents of both ECU and SOSU enthusiastically supported this concept and directed their respective vice presidents of Academic Affairs to proceed with establishing the ECU baccalaureate nursing program at SOSU. The goal of our joint project has been to provide a quality baccalaureate nursing educational experience to students enrolled on both campuses. Another major goal has been to enhance cultural experiences for our nursing students, with an emphasis on American Indian culture.

First of Its Kind

This project was unique in that there were no similar collaborative programs in Oklahoma at the time. Prior to this, a number of academic institutions in the state had delivered courses and programs electronically to other institutions. However, the difference between our project and other existing collaborative programs is that ECU placed a program coordinator from its faculty, Dr. Deborah Flowers, on-site at the SOSU campus. Other unique aspects of the collaboration were signing an articulation agreement with SOSU to accept its general education and science support courses in ECU’s program, agreeing to financial aid arrangements and having ECU award the degree.

Establishing the nursing program extension was technically challenging, because the ECU courses needed to be reformatted for live electronic delivery over the State Regents’ One-Net system of two-way interactive digital television (ITV) and enhanced with WebCT. Since the nursing faculty had no previous experience in distance education, ECU administration supported their efforts to attend conferences in order to learn these skills. In addition, laboratory space and equipment and clinical experiences had to be planned.

To fund the project, the Oklahoma State Regents for Higher Education provided ECU with a continuing special appropriation of $250,000 (now reduced by budget cuts to about $225,000) and provided SOSU with a one-time $100,000 allocation to build and equip an ITV classroom and office space. Additional funding was achieved through a U.S. Department of Health and Human Services, Health Resources and Services Administration grant funded through the Division of Nursing’s Basic Nursing Education and Practice program (BNEP). The grant, Extending Baccalaureate Nursing Education to Rural Oklahoma, was funded in 2000 for approximately $800,000 over three years. A second grant, Nursing Education with Enhanced Retention Activities (NEW ERA), is now in progress.

Community support to establish and retain the cooperative program has been outstanding. Local health care employers seek our nursing graduates and have actively supported our program. Clinical facilities and the Chickasaw and Choctaw Nations have funded professorial chairs to assist with faculty salaries. Two clinical facilities assist with part-time clinical faculty salaries. In addition, the Chickasaw Nation donates two textbooks to each entering sophomore student: R.E. Spector’s Cultural Diversity in Health & Illness (Sixth Edition) and Twiname & Boyd’s Student Nurse Handbook: Difficult Concepts Made Easy (Second Edition).

Setting the Stage

Once the full-time on-site program coordinator was designated, we needed to create a name for the distance education nursing program that would be acceptable to both schools. This required some political sensitivity, because for many years a rivalry had existed between the two institutions. After a certain amount of discussion, the name chosen for the program was ECU @ Southeastern Department of Nursing ([email protected]).

The next step was the development of the distance education site. Specific activities we needed to accomplish included:

1. Developing a liaison between ECU and SOSU and establishing relations with key persons and departments at SOSU.

2. Designating space for the new department, staffing it, and equipping it.

3. Developing policies and procedures relating to requirements for general education, nursing prerequisites, course substitutions, transference of financial aid, student registration and enrollment, and student transfers between campuses, as well as adapting existing ECU Department of Nursing policies and procedures for ECU @ Southeastern nursing students.

4. Developing and implementing a media plan for recruitment of a qualified student applicant pool.

5. Establishing clinical sites in the surrounding area and hiring clinical instructors.

6. Ensuring equal access to quality nursing education for students at both schools, including access to campus resources, student support services, student nursing organizations and faculty advisement.

The ECU @ Southeastern Department of Nursing was placed under the auspices of the SOSU Department of Biology, a division of the SOSU School of Arts and Sciences, with the chain of command beginning with the chair of the Biology Department. We held meetings with the various department personnel with whom the [email protected] program coordinator would be working. Qualified Department of Nursing office personnel were hired and the department’s computer, basic skills and physical assessment laboratories were fully equipped to replicate ECU’s laboratories. The SOSU Telecommunications Department oversaw the installation of two state-of-the-art ITV classrooms.

To ensure adequate numbers of qualified prospective students from which to select a nursing class, the ECU @ Southeastern Department of Nursing advertised to the SOSU catchment area, using a recruitment/media plan developed with input from an American Indian consultant and the ECU public relations director. The program coordinator, Dr. Flowers, met with nursing administrators to select qualified clinical sites; contracts were signed as per ECU protocols. Locating qualified clinical faculty in this rural setting was a challenge, but having available ECU graduates in the area has been an asset.

An articulation agreement between ECU and SOSU was developed, delineating the specific responsibilities each university would assume in the education of the [email protected] students. Both university presidents signed the agreement.

All of these activities took place over approximately 18 months while the distant site became operational. The first cohort of students to graduate from the ECU @ Southeastern Department of Nursing did so in 2002.

Focusing on Retention

While our first HRSA grant project focused on initiating a baccalaureate nursing program at SOSU, the current project is focused on student retention and successful graduation. Because of concern that the new nursing department’s retention rate was not as high as anticipated, we developed the second project with the goal of increasing retention in order to increase the workforce of culturally competent professional nurses who would be able to serve the area’s diverse communities. Nursing faculty and students in the [email protected] program are involved in a variety of retention activities. Some activities are didactic, others emphasize student orientation and advisement.



From the beginning, students are introduced to retention activities as part of their program acceptance packet. In an effort to communicate college expectations to students and their families, the department holds a “Back to School Night” for students and their significant others. The event is conducted in the first few weeks of the sophomore-level course and is transmitted via ITV with some nursing faculty at each site. The department chair welcomes students and guests, explains the program and underscores the students’ study time expectations. Each faculty member is introduced and the respective department sites are open for tours. This event also provides an opportunity to introduce and explain specific retention activities, particularly the Individual Observational Experience and the department’s friendly “invasive advisement.”


Invasive advisement is a proactive advising approach that the department has adopted. Following each unit exam, the project retention coordinator communicates with each student via the course Web site. Students are sent notes, which vary in content based on their test grades. Students in academic jeopardy are asked to make an appointment with the course coordinator or faculty to discuss issues that may be impacting their performance. The students are asked to identify work hours, study techniques and any other factors that may be affecting their academic success. Then faculty members assist the students in planning interventions, including referrals to university services, such as counseling for test anxiety, support services for study and test-taking skills, and tutoring arranged by ECU’s Native American counselor. The faculty document each advising session.

Individual Observational Experiences (IOEx) are offered to each sophomore-level student enrolled in the first clinical course. Students participate in a four-hour clinical observational experience in their choice of clinical settings. Four local clinical agencies generously pair staff nurses with students, most of whom have never worked in a hospital setting. The goal is to offer a realistic look at nursing from a “real” nurse’s perspective. The project director coordinates IOExs in concert with the Human Resources or nursing office staff at the participating health care facilities.

In addition, faculty have designed in-class activities, called Teaching-Learning Cultural sessions (TLCs), which promote student retention. TLCs are concentrated, lively 10- to 15-minute weekly sessions that cover a multitude of topics, such as health promotion, stress reduction and how to form an effective study group. For example, students may be asked to complete a schedule of their week, evaluate quality study time and determine realistic study goals. The schedules become the basis for TLC class discussion about time management. TLCs can also incorporate cultural or pathophysiologic topics relevant to the class lecture material.

Plus, clinical cultural sessions are held monthly during post-conference in most major clinical junior- and senior-level courses. Students from both the ECU and SOSU campuses attend these sessions to discuss cultural aspects of nursing care. Clinical faculty develop the sessions and facilitate discussion, which is held via ITV. For example: Students assess their assigned patient’s traditional health beliefs or home health practices, then share this information with their student colleagues. As part of the discussion, students also share their own family’s traditions. Additional clinical topics include beliefs related to the dying process, diabetic care and cultural or ethnic assessment findings. The textbooks by Spector and Twiname & Boyd serve as a springboard for both TLCs and clinical cultural sessions.

A culminating senior-level cultural experience occurs in the Community Health course. Students plan, implement and evaluate health career fairs and health assessments at local elementary and secondary schools that have a high percentage of American Indian students.

Bridging Boundaries

Developing and implementing this technologically complex collaborative project was often challenging, but the results we have achieved together have been more than worth it. Our first grant project’s goal of bringing baccalaureate nursing to rural southeastern Oklahoma has been successfully met: We have a vibrant extended nursing department which is flourishing in the distance education environment.

NCLEX-RN® pass rates are consistent across the two campuses and exceed the national average. This fall semester, the senior class will be the largest we have ever had, with 60 students. This represents a two-year average increase of over 10 students. The junior class has retained 71 of the original 74 students. Preparation of a new ITV classroom is in progress to accommodate the larger ECU campus site class size. We continue to maintain a higher enrollment of Native American students in the nursing program than the overall average percentage on both the ECU and SOSU campuses.

We have bridged many boundaries to build the ECU @ Southeastern Department of Nursing, not the least of which was the longstanding rivalry between the two educational institutions. Initially the two campuses had separate student nurse organizations, but now the two organizations are merging. Most clinical agencies in the area have been eager to accommodate [email protected] nursing students and faculty.

By extending ECU’s program to a sister university with an equally diverse student population, we have increased the accessibility of a baccalaureate nursing program that is well established and fully accredited. We continue to maintain a philosophy of providing quality nursing education to all students regardless of which campus site they attend. Faculty physically travel to [email protected] to originate at least 25% of didactic class sessions. The instructors’ sensitivity to promoting distant students’ class participation has been integral in achieving inclusiveness.

Classroom and clinical activities are designed to enhance student interaction across both campuses and to increase cultural sensitivity. Every junior-level student has at least one clinical day at the Chickasaw Nation’s Carl Albert Indian Health Facility. ECU campus senior students travel to the [email protected] campus for selected class activities. The program’s clinical cultural sessions and TLCs receive positive evaluations from the students.

An important benefit of this project is that we are helping to alleviate minority health care disparities in our area by reaching out to surrounding diverse communities to recruit our nursing students. We also conduct clinical activities in predominantly Native American secondary schools. In one of these schools, our senior Community Health students have conducted physical assessments and health career fairs for six years; the high school students look forward to the nursing students’ activities. Altogether, approximately 200 grade school and high school students per year participate in activities planned by our nursing students. At least one of these pre-college students has indicated that she plans to enroll in our nursing program when she graduates.

Most of the nurses we prepare at ECU and at ECU @ Southeastern remain in the area after graduation. Thus, our project has increased the numbers of culturally diverse professional nurses in the rural Oklahoma health care workforce. As more baccalaureate-prepared American Indian students continue to graduate from our program and embark on nursing careers, they will be able to provide enhanced culturally sensitive care to underserved populations who urgently need it.

Authors’ Note

The authors gratefully acknowledge the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing for its financial support of this project. We also wish to express our gratitude to the administrations at ECU and SOSU, and to the ECU Department of Nursing’s faculty, staff and students.

Voice of the People

Voice of the People

The smell of burning sagebrush, sweetgrass and cedar perfumes the air. A drum keeps time softly as voices quaver in song and prayer. A traditional American Indian smudging ceremony is in progress at Deaconess Billings Clinic (DBC) in Billings, Montana–a routine procedure per clinic policy, thanks to DBC’s Native American Patient Advocate, Lanette Perkins, BSN, RN.

For many Native peoples of Montana, Wyoming and the Dakotas, the mingling of smoke, breath and prayer in a smudging ceremony is believed to create more integrated spiritual and physical health or a more peaceful transition to death. “It gives them a chance to express their religious beliefs and center themselves for hope,” Perkins explains.

Many hospitals are reluctant to allow ceremonial smudging at their facilities, citing fire safety and other concerns. But the Native American Patient Advocate Program at DBC is demonstrating how, with thoughtful planning and a little extra effort, modern medicine can make room for traditional healing practices and cultural beliefs.

The smudging policy that Perkins developed for the clinic is “worded so that it’s not locked into just one culture,” she says. “At this time it might benefit one group of people, and one culture might be utilizing the policy, but it’s not exclusive to [Native American] culture.” Certain Asian cultures also perform similar ceremonies, Perkins explains. She has filled requests for copies of the policy from other hospitals, colleges and even an Aboriginal group in Ottawa, Canada.

It’s a Family Affair

Billings stands on the banks of the Yellowstone River, surrounded by forests, mountains and the Crow Indian Reservation. Deaconess Billings Clinic, which is the largest health care facility in the region, serves not only the usual mix of townspeople, ranchers and tourists but also Hutterites [a religious group whose beliefs are similar to the Amish] and Native people representing more than 40 different tribes.

Determined to serve all patients effectively, DBC received grant funding from the Rocky Mountain Technology Foundation to establish the Native American Patient Advocate Program, believed to be the first of its kind in the United States. Perkins was hired to implement the program and has been on the job for three years now. She works with patients, their families, hospital staff and tribal leaders to eliminate cultural barriers that could affect the quality of care Indian patients receive.

“When I go into a room [to meet with patients and family], I hope I can be helpful,” Perkins says. “The first thing they want to know is, who’s your mother–or in my case, who’s your dad. My dad is Crow and my mother was German, and I also have Chippewa and Cherokee ancestry. [The nursing profession frowns on nurses discussing their personal lives with patients], but there are no big secrets in my family and this the only way I can get my patients to trust me and start to work with me. The trust part is the biggest issue.”

Establishing that trust starts with introducing yourself, she continues. “I usually go around the room and introduce myself [to everyone], and they will usually tell me their name and how they are related. Some of them like a light handshake–not a heavy handshake, which may seem like a sign of aggression, but a light handshake.”

In North Plains tribes, according to Perkins, “anyone in your generation could be considered your brother or sister, even if they may actually be a very distant cousin.” Similarly, anyone in the parents’ generation may be considered a father or mother, and so on. Most hospitals are not used to accommodating such large extended family groups, but for Perkins it’s another vital function of her job as patient advocate.

For each patient, she says, “I find the family spokesperson, usually a lady about my age, because most Montana tribes are matriarchal. I talk with her and find out who is in the family and make a list. This helps the clinic staff recognize who is family to be contacted in case there is an emergency, and who will be visiting the patient. I also sort out who are the biological parents, siblings and spouse, because when it comes time for health care decisions, we need to make sure that we speak with what would be recognized in Western culture as the core family.”

Mediating and Educating

Perkins estimates that about 60% of the staff at Deaconess Billings Clinic like the way her program seeks to adapt hospital routines to meet the cultural needs of Native American patients, but about 40% see her as an obstacle that makes it harder to do their jobs.

“I tell them, I’m not the ‘Indian Police,’” she says with a chuckle. More seriously, she adds, “I tell them, if you see me walk into your area, don’t get nervous. If I ask to have you reassigned to another patient [because of problems in establishing an effective relationship with an Indian patient], don’t think of it as a negative. Think of it as a positive: Something’s not working out well and we have to make a change [in order to provide the best possible care for that patient].”

Indeed, some of her nurse colleagues are more than willing to ask Perkins to intervene when such problems occur. “They’ll call me if there’s something that’s not going right,” she explains. “They’ll say, ‘Lanette, can you come up and see what you can do to help?’ And if there are people [who may feel threatened by] what I do, that’s an issue that they’ll have to get past.”

In addition to acting as a mediator and resolving cultural misunderstandings that may arise between Indian patients, families and staff, Perkins’ job functions also include providing cultural competency training for clinic staff. “Every two weeks, I do a portion of our new staff orientation program and we talk about culture,” she says. “[I explain that] culture can be nurses to nurses, department to department, and then we get into the [ethnic cultural differences]. We talk about respect, listening and communication. I use the University of Minnesota video ‘Getting to the Heart of It: Bridging Culture & Health Care’ to get the staff thinking about their communication style.”

Many experts agree that communicating with respect is an essential element of cultural competence. “[In a busy health care setting,] we get wrapped up in what we’re doing, we get into a hurry and forget to take time to be respectful,” Perkins observes. But she emphasizes that “it doesn’t matter whether it’s a patient or a co-worker, we need to be respectful.”

While her official title is Native American Patient Advocate, Perkins says she’s available to advocate for anyone who needs cultural assistance. “For example, we had an Aboriginal lady from Australia in our mental health facility,” she recalls. “They had her there for three or four days and couldn’t figure out [how to communicate] with her, so they decided, ‘Why don’t we call Lanette and see if she can help?’

“I went over and just did the listening strategy. I asked questions, letting her be the teacher. It was one of my most interesting and rewarding experiences, because I learned a lot about Aboriginals. We found out what the patient’s issues were and we were able to discharge her in three or four more days.”

A Personal Cultural Journey

Recognizing that historically the North Plains tribes were often at war with each other, Perkins invests time and energy in developing relationships with various tribal leaders. She visits reservations and last year she organized a multi-tribal conference at the clinic. “If I’ve had personal, face-to-face interactions with people, the next time I call them on the phone it goes a hundred times better,” she observes. “I never take those relationships for granted. I feel blessed when I go and talk with the tribal leaders and we work together as a team.”

Perkins’ nursing career reflects aspects of her own heritage that are meaningful to her. “My German grandmother was a teacher,” she remembers, “and my Indian grandmother was a certified nurse’s aide. She kept talking to me about nursing. In high school I worked as a nurse’s aide and I wanted to be a nurse.”

She enrolled in Montana State University, but her Indian scholarship was revoked on a technicality. She worked two jobs to pay her own way but was able to struggle through only five quarters of college. Though she never completely gave up on her dream of becoming a nurse, she did have to put it on hold for a while.

“I started my family and for 12 years I had a courier business,” Perkins says. “Mine was the only woman-owned, minority-owned transportation business in the state of Montana. I had contracts with the city, the county, Montana Power. I learned about business, customer service, how to write contracts and how to do a lot of things under state and federal regulations.

“Then, unfortunately, my husband became disabled and couldn’t work, so I had the opportunity to go back to school on scholarship,” she continues. “I went to Salish Kootenai College in Pablo, Montana, and got my ADN. But partway though I realized that for some of the things I wanted to do as a nurse, I should at least have my bachelor’s. So I took extra classes as part of my ADN program. I graduated in May, took my state boards in July and in August started the bachelor’s program at Missoula. I got my BSN in three more semesters. I didn’t want to move my family again, so I stayed in Missoula and worked for the Indian Health Service till my son graduated from high school.”

In many respects, Perkins’ current role of patient advocate is a logical progression in her personal cultural journey. She admits that “I took a chance when I came to Deaconess, because they didn’t have the program all developed,” but she’s glad about how everything has worked out. “For me it has been a real opportunity to learn and to build,” she says.

In addition to her work at the clinic, Perkins mentors students in the Caring for Our Own Project (CO-OP) at the Montana State University College of Nursing. This nationally recognized program is designed to increase Native Americans’ access to culturally competent health care by recruiting, retaining and graduating Native nursing students.

Perkins also serves on the board of directors of the National Alaska Native American Indian Nurses Association (NANAINA). She values the opportunity of getting to know other Indian nurses through NANAINA and hearing their success stories.

As for where her own story will eventually lead, Perkins speculates that “one of these days, I’ll go back to school and get my master’s in nursing education. I want to teach. One of my grandmothers was a teacher and one was a nurse, so I’d be combining both of their vocations. Both are important components of me.”

Baccalaureate Nursing in Rural Oklahoma: Strategies for Success

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