This summer, the University of North Dakota College of Nursing conducted three four-day tours across North and South Dakota, Minnesota, and Nebraska, visiting American Indian reservations in an effort to recruit potential nursing students. Sponsored by the University’s Recruitment and Retention of American Indians into Nursing Program (RAIN), the tours gave students on the reservations a glimpse at the nursing program and all it has to offer, says program coordinator Deb Wilson. In turn, faculty and staff participating in the visits gain a better understanding of the reservations and students’ cultural backgrounds.
Native Americans and Alaskan Natives comprise about 6% of North Dakota’s population, according the U.S. Census Bureau, compared to less than 2% of the U.S. population as a whole. Federally recognized tribes in the state are the Spirit Lake Tribe (formerly the Devil’s Lake Sioux), the Three Affiliated Tribes of the Fort Berthold Reservation, and the Turtle Mountain Band of Chippewa Indians.
Are you looking for a nursing career that’s different from the “same old same old?” One that offers variety, challenge and opportunities to work in many different parts of the country? A deeply fulfilling career that gives you a chance to make a real difference in addressing some of the nation’s most serious minority health disparities? Then consider a career with the Indian Health Service (IHS).
There are more than 560 federally recognized American Indian and Alaska Native tribes located throughout the United States. The Indian Health Service, a federally funded agency within the Department of Health and Human Services, is the primary health care provider and advocate for approximately 1.9 million of the nation’s 3.3 million American Indian/Alaska Native (AI/AN) people. About 57% of AI/AN people in the U.S. depend on IHS for a wide range of health care services, including hospital care, clinical care, dental and pharmacy services.
These are particularly exciting times for nurses to pursue careers in the Indian Health Service. President Obama’s fiscal year 2010 budget authorized one of the largest IHS funding increases in 20 years. As a result, the agency now has a $4.03 billion operating budget directed at supporting and improving health care services, improving health outcomes, promoting healthy communities and addressing health disparities. Last year the IHS received a $500 million allocation of American Recovery and Reinvestment Act funds to help pay for new health care facilities, health information technology, medical equipment and other improvements in the delivery of health care to AI/AN communities.
A Unique Mission
Although the IHS as we now know it was established in 1955, earlier efforts to provide some type of federally funded health care for Native people date back to the 19th century. By 1921, the Snyder Act authorized the use of federal funds to provide health services to federally recognized tribes, which are sovereign nations that have a government-to-government relationship with the United States. The Snyder Act approved funds “for the relief of distress and conservation of health. . . [and] . . . for the employment of . . . physicians . . . for Indian tribes throughout the United States.
“Today the Indian Health Service provides a comprehensive system of health care services to AI/AN people living on or near tribal reservations, in rural communities and in urban settings. Headquartered in Rockville, Md., just outside the nation’s capital, the agency has 12 local area offices across the country, mostly in the Western U.S. and Alaska. The IHS operates 31 hospitals, 63 health centers, 30 health stations and 34 urban Indian health projects.
During the 1970s, landmark legislation such as the Indian Self-Determination and Education Assistance Act gave tribes the option of contracting with IHS to operate and manage their health care services themselves, rather than receiving services directly from the agency. As a result, there are currently 14 hospitals, 240 health centers, 102 health stations and 166 Alaska village clinics that are run by tribal governments.
Through both federally operated and tribally contracted health programs, the Indian Health Service’s goal is to ensure that all AI/AN people throughout the U.S. can receive health care that is accessible, comprehensive and—most importantly—culturally acceptable.
“The thing that is distinct about working for the Indian Health Service, besides the fact that it is a federal agency with a direct clinical service delivery mission, is the fact that the American Indian/Alaska Native people still have much of their [traditional] culture intact,” says Carolyn Aoyama, CNM, RN, MPH, the agency’s senior consultant for women’s health. “American Indian culture is very different from the dominant culture.” For non-Native nurses, she adds, having the opportunity to learn about and work within a culture that is so different from their own can be a tremendously enriching experience.
Culturally appropriate nursing care can play an important part in helping to eliminate the severe health disparities that are rampant in AI/AN communities. According to IHS statistics, the life expectancy of AI/AN people is almost five years shorter than that of the general U.S. population, and they have significantly higher mortality rates from tuberculosis, alcoholism, diabetes, automobile accidents, unintentional injuries, homicide and suicide.
“Diabetes is the predominant diagnosis that we see,” says IHS nurse Devon McCabe, RN, a member of the Navajo nation in Leupp, Ariz., who works as an ICU supervisory clinical nurse at the Gallup Indian Medical Center in Gallup, N.M. “My goal is to get these patients out of the hospital and [help them stay] healthy. I stress to my staff that educating our patients is a top priority. Patients need to be self-aware about their diseases and understand their diagnosis.”
Nurses Urgently Needed
The Indian Health Service currently has a nursing workforce of more than 2,500. But like many other health care employers that have been impacted by the nursing shortage, it has struggled to recruit and retain nurses, in in-patient, outpatient and public health/community health settings. Last year the agency’s overall nursing vacancy rate was 26%—compared to 21% for physicians and 11% for pharmacists. Therefore, nurses interested in exploring careers in the IHS will find great demand for their skills and an exciting variety of opportunities to choose from, especially if they are willing to work in rural, medically underserved locations.
A Coast-to-Coast Commitment to Improving INdian Health In addition to its national headquarters near Washington, D.C., the Indian Health Service comprises 12 regional areas:
Aberdeen Area (North Dakota, South Dakota, Iowa, Nebraska)
“Here on the Navajo reservation, hiring is one of our top priorities,” says Jeannette Yazzie, BSN, RN, nurse consultant for the Navajo Area IHS office in Window Rock, Arizona. “I have a nurse recruiter at each one of our facilities. We’re just in the process of reestablishing a region-wide recruitment and retention group which will include not only nursing staff but also physician and pharmacy staff. Our greatest need for nurses right now is in OB and ICU. Medical-surgical nurses are always needed.”
The IHS also needs more advanced practice nurses, including nurse practitioners, nurse-midwives and nurse anesthetists, adds senior national nurse recruiter Celissa Stephens, MSN, RN. “The vacancy rate for APNs has been going up every year for the past four years,” she notes. “Advanced practice nurses have a lot of autonomy and responsibility within the Indian Health Service, and in general the risk status of the population and the patients that they’re going to be serving will be higher.”
IHS nurses have the option of working either for the agency or for tribes. Nurses hired by tribally operated facilities are employees of the tribes, which typically determine their own salary levels and benefits packages. Nurses who work at IHS-run facilities are employees of the federal government and can choose to be either civil service employees or members of the U.S. Public Health Service Commissioned Corps.
According to Stephens, salary rates for federally employed IHS staff nurses are competitive with the national average for the private sector. Nurses will also find plenty of opportunities for professional growth, including training programs, education programs and leadership development.
The agency also offers a loan repayment program as well as a scholarship program to assist staff members who wish to advance their professional education. Each year the IHS awards scholarships to help AI/AN nurses complete their bachelor’s or master’s degrees while maintaining their full salary and benefits. “That’s how I earned my master’s degree,” says Stephens.
Traveling Many Paths
If you thrive on versatility and variety, rather than doing just one type of nursing in one location, then a career with the Indian Health Service is for you. IHS nurses typically handle a wide range of medical and public health situations, and they must be open to performing duties that fall outside those of traditional nursing jobs at private sector health care facilities. Plus, working for the IHS gives you the opportunity to move around the country and work with a variety of different tribes and cultures.
“On most of our reservations, when we’re looking for OB nurses for example, we [want] them to be able to work a whole range [of nursing functions],” explains Yazzie. “We want them to be able to [provide care to the mother] before birth, after birth, and then provide care to the baby.”
In her 25-year career with the IHS, Yazzie has journeyed both geographically and professionally. “I initially started as an ICU nurse in 1983,” she says. “Being Navajo and growing up for part of my life on the reservation, I always knew I wanted to work there and assist my people in whatever way I could. Working for the IHS has been very rewarding for me. It has taken me many places and given me numerous opportunities [to advance in my career].”
Over the years, Yazzie has worked in Washington state with the Yakama tribe, at the Whiteriver Indian Hospital on the White Mountain Apache reservation and at Indian Health Service facilities in Phoenix, Ariz., and Alaska.
Similarly, Stephens, who is a member of the Choctaw nation of Oklahoma, has worked for the IHS since 1989 and has held a variety of positions, including ICU nurse, manager of a med-surg unit, clinical nurse specialist, clinical nurse consultant and chief nurse consultant.
For nurses who love the outdoors, the IHS offers opportunities to work in some of the country’s most beautiful, unspoiled natural settings, from the spectacular landscapes of Alaska to the Big Sky Country of Montana. In Arizona, for example, there are plenty of activities for an outdoors person, including walking, biking, hiking and many national parks and monuments to explore. If, on the other hand, you’re someone who prefers to live and work in a city environment, there are IHS urban Indian health programs in metropolitan areas like Chicago, Denver, Dallas, Los Angeles, Minneapolis, San Diego, Boston, Milwaukee and Tucson.
All Nurses Welcome
Unfortunately, many non-Native nurses fail to even consider the possibility of pursuing a career in the Indian Health Service because they mistakenly believe that only American Indians and Alaska Natives are eligible to work for the agency. This perception, though common, is not true. While the IHS is federally required to give hiring preference to AI/AN people first, nurses of all races and ethnicities are encouraged to apply. Currently, only about half of the IHS nursing staff is American Indian or Alaska Native (see below).
Who are today’s Indian Health Service Nurses? Source: Indian Health Service, August 2009
Aoyama is an example of a non-Native nurse in a leadership role within the IHS. “For me it’s been fabulous,” she says. “I love working in this agency. It’s a mission-driven organization that is very clear about its purpose. There’s never any mistake about what the purpose of your work is and who you are serving, and I thrive in organizations like that. I find the people to be very generous in helping me understand the culture.”
Being open to learning about, adapting to and embracing AI/AN culture is definitely a key requirement. Yazzie says that the non-Native nurses she hopes to recruit are always offered the chance to come and visit the Navajo reservation, or any other reservation, because the culture and lifestyle is so different from the majority culture.
“It’s not like the big city,” she warns. “Some of our reservations are pretty isolated and remote. Some people [who have never been to a reservation] are quite shocked at the distances we [have to] drive and the fact that we still have homes with outdoor [bathroom] facilities, no indoor plumbing and no electricity. People will ask me how far away the nearest Walmart is and I tell them that it’s 60 miles away.
“The realities of reservation life are nothing like what is portrayed in Hollywood “cowboys and Indians” movies, Yazzie emphasizes. “I think some people out there in the world still believe—and I’m hoping that this stereotype is lessening—that Native Americans are like the people they see on their television set,” she says. “[Sometimes non-Native nurses come into IHS] thinking that they are going to ‘rescue’ us. We certainly don’t need to be rescued.”
Stephens agrees. “Despite the Anglo cultural view that not having [modern amenities like] heating and plumbing is a detriment, these communities choose to maintain their lifestyle and culture. Another benefit of working for the IHS and working out in the field is that you have the opportunity to be embraced by the community. You learn so much about that community.”
For some IHS nurses, learning about AI/AN culture and traditions may also mean learning a new language. Some tribes maintain their original languages to keep this part of their cultural heritage from disappearing.
Who are today’s Indian Health Service Nurses? Source: Indian Health Service, August 2009
“[Language barriers] are definitely a concern that some [potential nursing employees] have,” says Yazzie. “I’ll have people call me and talk about wanting to come and work with the Native American population, and oftentimes they [ask] if they have to be Native and do they have to speak the language.”
“I remember when I worked with the Navajo nation in 1975,” says Aoyama. “I had to have an interpreter because I couldn’t speak Navajo. It’s very different and [extremely difficult to learn]. You [really] have to learn the language as a child.”
Even though the IHS is working to attract more nurses from diverse racial and cultural backgrounds into its workforce, it will always have a particularly strong need for more American Indian and Alaska Native nurses who are culturally knowledgeable and deeply committed to improving the health of other AI/AN people, especially in their own tribal communities.
“If a [non-Native] nurse wants to work for us, they have to be open-minded and want to learn more about people in general,” says McCabe. “The people that I care for are part of my tribe and that’s the catalyst for what I do.”
To learn more about nursing career opportunities in the Indian Health Service, including current job openings, visit www.ihs.gov/MedicalPrograms/Nursing.
“Things change when Indian people get inside federal policy-making organizations, and it’s exciting to see that happen,” says Captain Pelagie “Mike” Snesrud, RN.
Snesrud, a Certified Public Health Nurse and career officer in the U.S. Public Health Service Commissioned Corps, is literally in a position to know. In January 2002 she was appointed to a key policy-making position at the Centers for Disease Control and Prevention (CDC) in Atlanta: She is the Senior Tribal Liaison for Policy and Evaluation in the Office of the Associate Director for Minority Health.
In this capacity, Snesrud–whose tribal affiliation is Dakota from the Shakopee Mdewakanton Sioux Tribe–serves as the office’s primary point of contact for leadership and coordination of the CDC’s activities supporting American Indian and Alaska Native health initiatives. She is responsible for helping to develop and facilitate CDC projects, programs and policies that benefit and improve the health status of Native American communities nationwide.
As her title implies, a key part of Snesrud’s role is acting as a liaison between the federal government agency and the nation’s 569 federally recognized Indian tribes, which are sovereign nations that have a government-to-government relationship with the United States. With her more than 24 years of experience working with Indian health programs and her distinguished record of effective leadership working with tribal elders, tribal governments, and local, state, regional and national public health programs and agencies, it is easy to see why the CDC sought her out for this important post.
Mike Snesrud’s nursing career over the past 30 years has been remarkable and determined, showing a singular drive and ambition to serve the Indian community, be a role model to other Indian nurses, and balance this work with her equally important responsibilities as a wife and mother of four children. A closer look at her professional path clearly shows it is no accident that she has arrived at her destination as a national leader in Indian health today.
Setbacks and Successes
Snesrud grew up in Shakopee, Minn., on land indigenous to the Mdewakanton people. In 1974, after graduating from Winona State University with a BSN degree, she embarked on her career as a public health nurse. She worked for the City of Bloomington (Minn.) Health Department for four years. From the beginning, the young nurse’s goal was to work with American Indian people after she had obtained sufficient experience in the field.
Moving to Kansas with her husband, a teacher, in 1978, Mike obtained a position at the Douglas County Health Department. Within six months, however, she faced her first big professional disappointment: She was dismayed to find that the agency’s level of commitment to minority health did not measure up to her experience in Minnesota, a leader in the nation’s public health system. Although Douglas County was rich in resources, she recalls, many of its minority residents did not have adequate health care available to them.
Frustrated by this situation, Snesrud transferred to Lawrence Memorial Hospital in Lawrence, Kan., to work on the surgical floor. In this acute-care setting, where patients only came to her when they were very sick and left shortly after surgery, she realized the limitations of hospital nursing and that public health nursing was indeed her true calling. “We didn’t get to see the whole picture,” she explains, “and I learned that I preferred to interact with patients in their own environment, where they were in control.”
A major turning point came in 1980, after Snesrud had given birth to her fourth child. She was recruited to work at the Haskell Indian Junior College (now known as Haskell Indian Nations University) Ambulatory Care Clinic in Lawrence. It was here that she first began her service to Native people and saw firsthand the importance of having Native health professionals providing care as well as administrating programs. In addition to accepting her new position at the college, Mike decided to keep working about 30 hours per week at the hospital–partly to provide more income for her growing family and partly to help enhance the communication between the two organizations.
Simultaneously, she was asked to serve as a clinical instructor with nursing students in the new RN Program that had been established at Haskell. The Native nursing students needed a hospital rotation and it made sense to have Snesrud, who was already known and trusted by the hospital staff, assist in forging a closer relationship with the Haskell nursing program staff and students. Many of the American Indian surgical patients treated at Lawrence Memorial were also clients of the college’s clinic, and Mike saw this as an opportunity to bridge a partnership between the two health care facilities.
Drawing on her strong administrative and leadership skills, she played an important advisory role in the expansion of the college’s nursing program. As a clinical instructor at Haskell, she was able to regularly bring a troop of nursing students to the hospital on a weekly basis.
Unfortunately, a lack of institutional support prevented the nursing program from flourishing. In two years it folded altogether, which was a huge disappointment to Mike, other Native nurses and the college. During this period, however, the health director for the Fond du Lac Band of Lake Superior Chippewa in Minnesota began to call her every six weeks in hopes of recruiting her to head his public health nursing program. His goal was to hire a Native nurse from Minnesota who had a strong commitment to improving the health of Indian people. So in 1982, Snesrud accepted the position and moved back to her roots in Minnesota, where she stayed to nurture her public health career and raise her family for the next 20 years.
“An Amazing Opportunity”
When Mike first arrived at the Fond du Lac reservation, the Human Services Division was in its infancy stage, with a staff of only eight health and social services personnel. But by the time she left in 2002 to accept her appointment at the CDC, it had become one of the premier tribal health programs in the nation and a shining example of how health care staff can collaborate successfully with tribal governments.
Some Current Indian Health Initiatives at the CDCBreast and cervical cancer early detection
Breast and cervical cancer early detection
National Diabetes Prevention Center
Water fluoridation programs
Tobacco use prevention programs
Injury and family violence prevention
HIV/STD surveillance, prevention and education
Hepatitis investigations and prevention
Immunization promotion, tracking and evaluation
Arctic Investigations Program–Infectious Disease Prevention and Control for Alaska Natives
For more information: CDC Office of Minority Health, www.cdc.gov/omh
Under Snesrud’s leadership, the public health nursing program grew to encompass a staff of 48; 75% of them are Indian people, many from the Fond du Lac community. One of its most successful initiatives was a maternal-child health program that provided care to 98% of the community’s pregnant women. It included a check-up program that provided a minimum of six home visits during a child’s first year. As a result of these visits, children’s immunization rates improved from 30% to more than 90%.
The 1990s brought many more opportunities for Mike Snesrud to demonstrate her exceptional leadership skills in highly visible executive positions. In 1993, she became the first president of the newly formed National Alaska Native American Indian Nurses Association (NANAINA). Between 1995 and 1997, she was chair of the Indian Health Service’s National Council of Nurse Administrators (NCONA), which represents nurse administrators from IHS, tribal and urban Indian health programs. From 1996 to 2001, she represented tribal public health nurses on the National Council of Nurses (NCON). Currently, Snesrud is the project officer of a CDC cooperative agreement with the American Indian Higher Education Consortium (AIHEC), a professional association representing 34 tribal colleges in the U.S. and Canada.
Speaking at NANAINA’s eighth annual national summit last year in Oklahoma City, Mike called her CDC appointment “an amazing opportunity for an American Indian public health nurse”–an opportunity to serve as a powerful voice that can speak up for the needs of Indian tribes at the highest level of federal health policy making and program development.
“The CDC is a huge bureaucracy with very specialized Centers, Institutes and Offices, and it can be very hard for tribal leaders to relate to,” she says. “That’s why it’s so essential to have someone inside the CDC who can be an advocate who says ‘what about tribes?’ and can build a circle of players that will come together to help Indian people.”
“Native Nurses Are the Cream of the Crop”
A Conversation with CAPT. Pelagie “Mike” Snesrud, RN
Minority Nurse:When you first arrived at the Fond du Lac reservation in 1982 [to become director of public health nursing for the Fond du Lac Band of Lake Superior Chippewa], what were the biggest challenges you faced? Mike Snesrud: There was a lack of trust between the Native people in the community and the medical and nursing staff. In the past, county workers did home visits and reported back that they thought the Indian children were not being cared for properly. As a result, sometimes children were taken away and family life was disrupted. Families consequently were extremely hesitant to allow nursing staff to come into their homes and their community. We had to earn the trust of the community and the tribal council. There was not an Indian hospital on the reservation, so Native patients were referred to one of four non-Indian hospitals. There was a lot of prejudice and resentment on both sides because of historically bad relationships and this needed to be addressed to ensure Native people received the quality care they deserved.
MN: How were you able to make improvements at Fond du Lac? MS: I helped develop cultural sensitivity and competency in our health care team—the home health aides, the community health representative, the nursing and physician staffs. Many of the providers who were non-Indian did not have a good understanding of where the Indian community was coming from [culturally]. Some of the elders’ concepts of health and illness were very different from the physicians’. Many did not come in for health care until it was an emergency. Patients wouldn’t follow their plan of care and there was no follow-up. So the health staff had to be taught to do much more than the usual: arranging transportation, helping people to assess various programs for assistance, following up to ensure that the patient heard the right information, and allowing Indian people to own their health and well-being by making their own choices.
MN: Tell us about your own Indian background. MS: I am affiliated with the Dakota Sioux Tribe on my grandmother’s side and the Ho-Chunk Tribe on my grandfather’s side. I grew up in Shakopee, Minnesota, which was named that because of Chief Shakapay and the Dakota Sioux people who were present in the area for years. During the 1950s and ‘60s, the reservation nation wasn’t well developed and Indian people just were not treated very well. One thing that really stands out in my mind is the prejudice that was directed at me and other Native people as I was growing up. As long as we were quiet and invisible, that was fine. But when we spoke up, there was animosity and conflict.
MN: What inspired you to become a nurse? MS: I had an older sister who was an RN and I looked up to her as my role model. She practiced nursing for more than 40 years and often provided me with real professional expertise and visible nursing leadership that gave me high standards to work towards. I was about five years old when I attended her graduation from the Mayo Clinic, and I knew then that I wanted to get involved in health care somehow. My sister became a head nurse at the Shakopee Community Hospital and I began candy striping under her when I was about 11. During high school I became a nurse’s aide. I saw that nurses often were the ones who spent time with the patients and had the ability to impact them more intensely than physicians, so I opted to become a nurse.
MN: What are some of the challenges for Indian nurses in the 21st century? MS: Recruiting American Indians and Alaska Natives into the nursing profession and then recruiting Native nurses into tribal [health care] positions. Even though tribes and the IHS have many nursing positions open, it is extremely difficult to compete with other public and private hospitals and agencies that can offer higher salaries, sign-on bonuses and quick hires.
MN: How would you describe Indian nurses? MS: My feeling is that most Native nurses are the cream of the crop because they have had to go through many personal and professional challenges to get to where they are today. Almost 90% of Native nurses are the main breadwinners for the family. That means they juggle the scheduling of a career and raising their children. Many are single mothers who survived a lot of hurdles to get through nursing school.
MN: What was it like for you to have to balance the demands of being a nurse, wife and mother of four children? MS: My husband and I have been happily married for 32 years, marrying quite young when we were both still in college. Early on, we both agreed that we were committed to one another and to our children. We knew we needed a certain amount of resources to care for our family and it didn’t matter whether he or I got those resources. He totally supported me through nursing school and my various career choices that have helped me be successful, fully involved and free to try whatever I want to do. Public health nursing allowed me the flexibility to be very active professionally and also arrange many of my children’s activities around my work schedule, so I seldom, if ever, felt unable to get involved. Sometimes the days and workweeks got long, but when a family is the driving force and your professional role fits well with your personal values, life is fun and work is fulfilling.
MN: How did you ultimately move from your tribal health position at Fond du Lac to the CDC? MS: My experience at Fond du Lac had given me many different opportunities and skills. I liked interacting with people at all levels and impacting policy decisions. I was ready to diversify what I had been doing. Different people had been tantalizing me to work at the national level, but I had not actually considered a move until my children were through with school and moving on with their life choices. It was the right time and the position excited and challenged me.
MN: What are some of your responsibilities at the CDC? MS: I am a public health analyst for the Office of Minority Health/Office of the Director, and I function as a Senior Tribal Liaison for Policy and Evaluation. I help CDC Centers, Institutes and Offices (CIOs) to partner and work more effectively with tribes and Native organizations. I am a resource both within the agency and to tribes, to help connect people to work together on public health issues. One of the activities I have been engaged in is coordinating the CDC Tribal Consultation Initiative. Prior to my coming to CDC, a Tribal Consultation Work Group developed a draft consultation policy that needed input from tribal leaders. During May to November of 2002, I and other CDC staff took this policy out to 11 Regional Consultations in Indian Country to listen to tribal leaders give CDC specific guidance and recommendations about consultation and public health needs.
MN: What have your meetings with the tribal leaders accomplished so far? MS: The tribes needed to see that CDC was willing to take the time and interest to go out into Indian Country before formulating its Tribal Consultation Policy and Plan. CDC wants to work with tribes in many different areas of public health prevention and recognizes that tribes themselves need to be fully engaged in the process. CDC’s Office of Minority Health is just completing its review of the transcripts from the meetings and is distributing summaries back to the tribes of the recommendations from the consultation held in their region. Input and recommendations from the tribes will help constitute CDC’s tribal consultation policy and ongoing activities and relationships.
MN: What are some of the most critical public health issues affecting Indian communities? MS: CDC and other federal agencies need to assist tribes in developing and expanding a Native public health workforce with the experience and training to deal with the unique needs of their population. Native nurses, doctors, epidemiologists, statisticians, environmentalists and scientists are all needed. Tribes need to have technical assistance and resources to build their infrastructure and capacity. Most important is good data that is accurate and readily available to tribes as they build their health programs and interventions. Assistance is needed not only in getting data but also in analysis and research.
MN: What about health disparities between American Indians/Alaska Natives and the majority population? What are some of the most common health problems that need to be addressed? MS: For hundreds of years Native people have not had access to quality health care. They are very entrenched in poverty and have a consistent lack of resources to deal with many basic issues in their communities. Much of what negatively affects Indian people today is related to preventable chronic diseases such as heart disease, cancer, diabetes, liver disease and lower respiratory disease, as well as preventable accidents and injuries. Pregnant women do not come in for early prenatal care, children and elders don’t always get the immunizations they need, and people do not wear seatbelts or ensure that their children are in car safety seats. Many Native people abuse alcohol, tobacco and other drugs and therefore do not make good choices. Rates of STDs and HIV are on the increase and there are not a lot of dollars for core public health activities.
MN: What advice do you have for other Indian nurses? MS: Nursing is a great career choice that allows you many different opportunities that fit with your individual goals and aspirations. It’s important for you to stay connected with your community and Native people, but also be willing to extend yourself and accept challenges based on the skills and strengths you have gained. Don’t be afraid to ask for help and then, in turn, to help and mentor someone else. Be willing to accept opportunities in a totally different environment than the one in which you are used to practicing. Federal agencies like the CDC, the Centers for Medicare & Medicaid Services, the National Institutes of Health and the Food and Drug Administration need Native people working within their organizations to help them to work more effectively with tribes, increase financial and other resources going to tribes, and to help cultural competency grow and systems change. Agencies need to be reminded about the sovereignty of tribes and the important role that tribal councils play on a daily basis.
MN: Anything else you’d like to add? MS: It’s an exciting opportunity to be part of such a dynamic and outstanding cadre of health professionals at the CDC. Working with CDC and the tribes is a huge challenge. CDC is a large federal agency made up of many very committed professionals who want to make a difference in decreasing health disparities. People often are willing to get involved when someone can assist them in talking to the right person at the right time. CDC and Indian Country have much to learn and share with one another to collectively address the public health of the nation as a whole.
In Saskatchewan, Canada, the most rapidly growing segment of the population is the Aboriginal (Native) community, which is expected to increase to 400,000 by the year 2040. The Royal Commission on Aboriginal Peoples estimates that in Canada as a whole, approximately 10,000 more Aboriginal health care professionals will be needed in the next 10 years to respond to the health challenges experienced by Aboriginal people and to meet this population’s preventive, diagnostic, treatment and rehabilitative needs. There is an especially strong need for more Aboriginal nurses and nursing researchers. Currently, less than 1% of registered nurses in Canada are Aboriginal.1
The Nursing Education Program of Saskatchewan (NEPS)–a collaborative program of the University of Saskatchewan, the Saskatchewan Institute of Applied Science and Technology (SIAST) and, as of March 2003, the First Nations University of Canada–values research as a core competency for undergraduate nursing students. The program also recognizes the critical need to build Aboriginal nursing research capacity. For these reasons, NEPS has developed a capacity-building initiative that is supporting and enhancing research expertise among Aboriginal nursing students.
The students work with researchers, Aboriginal communities and NEPS faculty as part of an inclusive research environment. While the short-term outcomes are exciting, this initiative demonstrates even greater promise for building and sustaining research capacity for Aboriginal nurses over the long term.
Learning from the Literature
A review of the nursing literature indicates that a number of articles have been written about the process of building research capacity in organizations and institutions. According to a 1999 study by Jennifer Rowley published in the International Journal of Education Management, the first stage of research capacity building focuses on the development of research teams, personal growth, support and guidance for members of the team and a continuous learning environment. The second stage is the integration of these elements into the greater academic community. The study also states that “…research leaders have responsibility for establishing a sense of direction and for the facilitation of opportunities to support the individual learning of others.”2
Rowley lists the four key elements for successful research planning as ownership, objectives, outcomes and organization. She suggests that ownership requires a participative and collaborative approach to designing and monitoring the research activity: “Ownership can only be achieved if all researchers (from research students to professors) have involvement in the planning process, and, conversely, if all participants in the planning process are active researchers.”
The team needs to support individuals who are at varying stages of their educational development, Rowley notes. In addition, the team must have a sense of vision, a plan for the research activities that can be completed during an expected time frame, and must define the general purpose of the research, the subject focus and the anticipated networking. The outcomes should link to the objectives of the research and should be able to be disseminated through activities such as presentations, conferences, Web sites, student projects and publications. For success in building research capacity, an organization must have a strong infrastructure as well as strong, creative individuals who contribute to the overall research culture.2
Another, more recent (2003) study indicates that undergraduate nursing students are capable of performing qualitative data analysis with proper guidance and support. Furthermore, students at this educational level are able to apply the steps of a content analysis to data they collect and begin to conduct a thematic analysis.3 This study also found that there was “improved student performance in the subsequent research process course [and] in other courses requiring application of research skills.”
Other recent studies have found that teaching nursing students to conduct all parts of the research process, with guidance from professors, prepares them for the realities of health care practice.4, 5, 3
Building Capacity through Collaboration
Currently, close to 200 students of Aboriginal heritage are enrolled in the Nursing Education Program of Saskatchewan, representing approximately 14 % of the student population. NEPS is a four-year program leading to a Bachelor of Science in Nursing (BSN) degree awarded by the University of Saskatchewan. SIAST offers years one and two in Saskatoon and Regina; First Nations University of Canada, Northern Campus offers years one and two in Prince Albert; and the College of Nursing, University of Saskatchewan offers years three and four in all three cities.
SIAST’s Native Access Program to Nursing (NAPN) is a nationally and internationally recognized recruitment, support and retention program and is a significant factor in the success of Aboriginal students in the NEPS. Student advisors (three at the Saskatoon site and one at the Regina site) provide academic and personal advisement, tutoring, mentoring and culturally appropriate counseling. The advisors are also available to assist students with childcare, housing and funding concerns.
Over the past three years, the NEPS faculty and NAPN advisors have been involved in a number of collaborative initiatives funded by Prairie Women’s Health Centre of Excellence and the Indigenous Peoples’ Health Research Centre (IPHRC). IPHRC funds research in the areas of Aboriginal women’s health and culturally respectful health care for Aboriginal people. It also funds Summer Undergraduate Research Awards for students.
Each of these initiatives has identified the development of research capacity in Aboriginal nursing students as a fundamental goal. Students who are interested in participating in research projects must have a successful academic background, be enrolled in a health science program and have an Aboriginal heritage. This goal is embedded in the conceptual framework for building research capacity in NEPS, which is based on the standards for research set forth by the Saskatchewan Registered Nurses’ Association (SRNA). The specific foundational competencies applicable for nursing students on research teams require that the students:
Demonstrate openness to new ideas, which may change, enhance, promote or support nursing practice;
Incorporate evidence-based knowledge from research in nursing and other disciplines into nursing practice;
Read and critique research articles and reports in nursing, health sciences and related disciplines; and
Participate in a variety of activities as part of a research team.6
The following examples illustrate how these four competencies are incorporated into the learning experience of the Aboriginal nursing students in the NEPS:
Openness to new ideas. Several of the Aboriginal students who are enrolled in the NEPS are involved in the research capacity building. They function as members of the research team and participate in processes that are responsive to the participating Aboriginal communities and the research context. The students are encouraged to challenge the status quo and explore new options and opportunities to approach the topic of interest.
As part of their self-assessments and feedback about specific research projects, some students have commented: “I came to understand how to address the political agendas of others”; “I had problems being able to suspend my own experiences as an Aboriginal woman as I looked at the research–so it challenged my beliefs” and “openness to new ideas is what kept this research group together and functioning.”
Incorporation of evidence-based knowledge.Health planners and providers working with Aboriginal communities are increasingly in need of the most current and reliable research information to guide their decision-making and planning processes. Through their research experiences, the Aboriginal nursing students participate in knowledge exchange, culturally respectful research processes and relationship building. One of the students working with NEPS faculty and members of a Native community stated: “The experience reinforced the principles of primary health care and how to apply them in my workplace and the community.”
Evaluation and critiquing of existing resources.For each research project, student members of the team are assigned a primary area (topic of interest). For example, an emerging challenge in the area of research ethics in Aboriginal communities sparked an interest for one student, and she subsequently worked on the identification, collation and critique of the extant literature. Other students have conducted literature searches related to culturally competent care, community development and decision-making, and Aboriginal research methods. The knowledge the nursing students gain from this process contributes to the development and further refinement of research questions and methodologies.
The students have learned that conducting literature searches and reviews is a valuable experience. Their feedback reflects this: “Because of this experience, I now look for opportunities to participate or initiate research on my practice unit”; “I hope I can be an example to others as they watch me give care that is respectful and equal across cultures” and “I feel I have been rewarded with the knowledge I have taken away from this experience.”
Inclusiveness in the research team.The students are mentored by faculty through all phases of the research, from grant writing to dissemination of research results. Several of the Aboriginal nursing student researchers have been successful in obtaining undergraduate grants from the IPHRC and from Health Canada’s First Nations and Inuit Health Branch (FNIHB) to facilitate their development in health care research. The students have told us that being members of the research team is “a great learning experience. . . [I am] learning how to prepare documents for an ethics committee” and “this collaborative effort definitely gave me more insight on working with others for a common goal.”
Showcasing Students’ Success
Through a coordinated approach and organizational support at all levels, the ongoing development of research capacity with the Aboriginal nursing students remains a priority in the NEPS. Summer studentships, research assistant opportunities and community linkages all contribute to the eagerness of the students, the ongoing commitment by faculty and the positive response from the local Aboriginal communities.
The nursing students’ successes as researchers have been showcased through publication, presentations, newsletters and posters. This past February, three undergraduate students and one graduate student participated in a student panel as part of Research Day at the College of Nursing, University of Saskatchewan. The feedback from participants at the Research Day indicated a very positive response to the student presentations.
The momentum and positive energy from these research initiatives are contributing to new projects and grants and are enhancing the learning of all members of the research team. Moreover, the research capacity building continues even after the students graduate. One recent graduate has already enrolled in a Masters of Nursing program. Another continues, as a registered nurse, to be involved in funded research related to community development within an urban Aboriginal community.
These Native nurse researchers are leaders in both the nursing community and in the Aboriginal communities. They are demonstrating the positive impacts of research on the health of their patients and the enhancement of culturally sensitive nursing practice. The Cree word Sihtoskatowin captures the value of working together on research projects, providing ongoing support and building research capacity with Aboriginal nursing students.
The authors would like to thank the following Nursing Education Program of Saskatchewan (NEPS) students and graduates who provided statements that were used as quotes in this article: Alex Keewatin (student), Dwayne Nagy (graduate), Andrea Pouteau (student) and Nora Weber (graduate).
1. Royal Commission on Aboriginal Peoples (1996). Report of the Royal Commission on Aboriginal Peoples. Retrieved from http://www.ainc-inac.gc.ca/ .
2. Rowley, J. (1999). “Developing Research Capacity: The Second Step.” International Journal of Educational Management, Vol. 13, No. 4, pp. 208-212.
3. Reising, D.L. (2003). “Establishing Student Competency in Qualitative Research: Can
Undergraduate Nursing Students Perform Qualitative Data Analysis?” Journal of Nursing Education, Vol. 42, No. 5, p. 216.
4. Fazzone, P.A. (2001). “An Experiential Method for Teaching Research to Graduate Nursing Students.” Journal of Nursing Education, Vol. 40, No. 4, pp. 174-179.
5. Neafsey, P.J. and Shellman, J. (2002). “Senior Nursing Students’ Participation in a Community Research Project: Effect on Student Self-Efficacy and Knowledge Concerning Drug Interactions Arising from Self-Medication in Older Adults.” Journal of Nursing Education, Vol.41, No. 4, pp. 178-181.
6. Saskatchewan Registered Nurses’ Association (2000). Standards and Foundation Competencies for the Practice of Registered Nurses.
In the last two years, about a quarter of the babies born on the San Carlos Apache Indian Reservation in Arizona tested positive for methamphetamine. The Navajo Nation has seen a doubling of methamphetamine use on the reservation over the last five years. And on the Wind River Indian Reservation in Wyoming, assaults and criminal charges for drug possession tripled, thefts doubled and reported incidents of child abuse increased by 85% between 2003 and 2004.
Annette James, DPhN, BSN, RN, public health director, Mille Lacs Band of Ojibwe
These aren’t isolated cases. The grim statistics are cropping up throughout Indian Country.
“Methamphetamine is killing our people and devastating our communities,” Joe Garcia, president of the National Congress of American Indians, stated earlier this year in a “Call for Action” that included a request for a White House partnership to combat the problem.
Federal, state, tribal and private health care agencies are joining forces to tackle what many tribal leaders are calling a crisis. And nurses, of course, are working with other health care professionals on the front lines.
“Nurses play an important role,” says Love Foster-Horton, public health advisor for the federal Substance Abuse and Mental Health Services Administration (SAMHSA)’s Center for Substance Abuse Treatment. “They’re usually the first responders. They’re educated to know what to look for and they can serve as referral sources for patients to help them into treatment.”
People have abused methamphetamine for decades, but the problem is a relatively new phenomenon in Indian Country. Indian Health Service clinics first began seeing the signs about six years ago. Since then, the number of IHS patient services related to amphetamine abuse have more than doubled—to 7,004 contacts in 2005 compared to 3,000 contacts in 2000.
Today meth is the third most commonly used drug in Indian Country, says Dr. Anthony Dekker, associate director of clinical services for the Phoenix Indian Medical Center in Arizona. Alcohol remains by far the most frequently used substance, followed by marijuana.
Meth abuse has drawn much media attention because it has such an immediate and devastating impact on users. Alcohol, Dekker says, tends to be a slow killer. But chronic meth abuse causes anxiety, emotional swings and paranoia, often leading to violent behavior, including assault, homicide and suicide. “People start using it and end up in jail or end up dead,” he says.
Annette James, DPhN, BSN, RN, public health director for the Mille Lacs Band of Ojibwe in north-central Minnesota, says she doesn’t think of meth as a drug but as a toxic substance. Meth labs wreak havoc on the environment as well as on people’s lives, especially children.
“Meth just turns the user into a totally different person, and [as a result, the user’s children receive] no care,” says James, a member of the Creek and Seminole nations.
Meth addicts lose their appetites, so they neglect feeding their kids, she explains. And the chemicals used to make the drug are poisonous. Children found living around meth labs have to go through a decontamination process. “I don’t think we even know the effects on these children living in the environment where these substances are being cooked,” says James, who is finishing her master’s thesis on the effects of methamphetamine abuse and labs on young children. “It’s just so frightening what’s going on.”
In April, Kathleen Kitcheyan, chairwoman of the San Carlos Apache Tribe, told the U.S. Senate Committee on Indian Affairs that homicides and suicides on her reservation have spiked, most likely as a result of meth abuse. “The use, production and trafficking of meth is destroying my community—shattering families, endangering our children and threatening our cultural and spiritual lives,” she stated.
The highest rates of meth usage in American Indian communities are among people ages 15 to 44. Dekker says an estimated one-third of teens on reservations in the Southwest have experimented with meth.
Kitcheyan told of one patient who was brought to the San Carlos Hospital, high on meth and hallucinating. He was nine years old.
Meth usage seems to be equal among men and women. “Twenty years ago, [most Indian] women didn’t drink or do drugs,” says Judy Whitecrane, CNM, director of nurse-midwifery services at the Phoenix Indian Medical Center. But now, out of the eight or nine patients on the hospital’s maternity ward at any one time, at least one tests positive for methamphetamine use, she estimates. The drug can lead to a variety of complications for both the mother and baby. In the worst-case scenario it causes abruption. The placenta breaks away from the uterine wall, causing massive bleeding, killing the baby and threatening the mother’s life.
A variety of factors have led to the meth addiction epidemic in Indian Country. Meth use has increased in rural communities throughout the United States. Some drug cartels have targeted reservations, taking advantage of the complex web of jurisdictional issues that make prosecution more challenging. Poverty and limited resources also come into play.
For instance, of the 13,000 people who live on the 1.8-million-acre San Carlos Apache Reservation, 65% are unemployed. “We suffer from a poverty level of 69%, which must be unimaginable to many people in this country who would equate a situation such as this as one found only in Third World countries,” Kitcheyan told the Senate committee.
Furthermore, meth is relatively easy to produce. “It’s cooked up in the back of cars, in motel rooms and basements,” James says. “In the winter, some people [here in Minnesota] are using ice fishing huts on the lakes to make it.”
Plus, it’s cheap. “A lot of people use substances to treat feelings. When they’re numb, they don’t think about how bad they feel,” says CAPT Lonna Gutierrez, a family nurse practitioner at the Phoenix Indian Medical Center and an officer in the U.S. Public Health Service Commissioned Corps. “People will treat with whatever they can afford. If they can afford it, they’ll buy a bottle of Wild Turkey whiskey. If they can’t, they’ll sniff paint or use meth.”
Working Toward Solutions
While there are no easy solutions to a problem of this magnitude, the Indian Health Service, other federal agencies, private sector health organizations and tribal officials across the country are partnering to respond to the meth epidemic with culturally appropriate interventions. A variety of promising programs have been developed and are available nationally.
The Matrix Model outpatient drug and alcohol treatment program—which focuses on lifestyle changes, training in relapse prevention, education on dependencies and family involvement—now includes a culturally relevant component designed specifically for use in American Indian and Alaska Native communities. The patient questionnaire, for instance, uses interviewing techniques that motivate rather than confront people. As a result, patients are more likely to come forward because they don’t feel they are being judged or attacked, Foster-Horton says. Developed by the Matrix Institute on Addictions (http://www.matrixinstitute.org/), the Matrix Model has earned the support of SAMHSA, the IHS and many tribes, who are training their staffs to use the program.
In Montana, the Billings Area of the IHS has developed a four-step recovery program that combines traditional Indian medicine with Western psychological and recovery components.
White Bison (www.whitebison.org), an American Indian-owned non-profit in Colorado Springs, Colo., offers sobriety, recovery, addictions prevention and wellness learning resources to the Indian community, including a culturally appropriate 12-step program based on the medicine wheel. White Bison champions the concept of “wellbriety,” which focuses on the opportunity for recovered people to not just survive but thrive.
Rather than declaring war against drugs, wellbriety strategies declare healing, Foster-Horton says. “The belief is that if you declare war on something, you bring it in[to yourself].”
Tribes Fight Back
Annette James became interested in learning more about methamphetamine after seeing abuse of the drug run rampant through Oklahoma, where she went to nursing school. “I noticed that on reservations there was denial and not a full understanding of meth and meth labs and what they’re doing to the environment,” she says.
That situation is rapidly changing, though. Today many tribes are working tirelessly to address the meth crisis, and they are making progress. This past April, White Bison, the National Indian Health Board (NIHB) and the Native American Rehabilitation Association of the Northwest co-sponsored the conference “Taking a Stand Against Meth: Recovery Is Possible.” The conference featured many “what’s working” education sessions showcasing successful strategies being used by tribes in various parts of the country.
The San Carlos Apache Tribe held a meth forum earlier this year for the staff of all of its tribal programs and has created a Methamphetamine Prevention Coalition. Tribal police underwent training and the tribe revised its legal code to improve enforcement capability. The tribe also launched a media campaign to educate the community and implemented an outreach program for employees.
Similarly, the Mille Lacs Band of Ojibwe created a methamphetamine coalition to increase awareness in the community and among reservation employees after its chief called attention to the issue.
But much work still lies ahead. James says more research and training are needed for public health workers, social workers and nurses who work in Indian Country.
Tribal leaders have called for more resources and assistance from the federal government. Jefferson Keel, first vice president of the National Congress of American Indians, told U.S. senators that the IHS and tribal health programs are funded at less than 60% of the level needed to provide adequate health care services. Among other steps, he called for central coordination of federal Indian Country methamphetamine resources, more funding for tribal anti-meth efforts, an increase in SAMHSA grants and at least enough IHS funding for the agency to maintain current services so it doesn’t fall further behind.
“Special Care” for Addicted Moms
Hospitals and clinics in Indian Country are also strategizing about how they can better serve their patients who are suffering from meth addictions. Here, especially, nurses and nurse-midwives are making significant contributions.
After seeing a growing number of pregnant women using methamphetamine, nurses and midwives at the Phoenix Indian Medical Center met with substance abuse counselors and pediatricians to figure out how to address the problem. They researched best practices and examples of successful model programs to develop an evidence-based intervention. The result was the creation of a Special Care Clinic to offer mental health and substance-abuse counseling and treatment to pregnant women with drug, alcohol or behavioral health problems.
The clinic’s substance abuse counselors are all American Indian women, and the clinic is in the same building where patients get their regular prenatal care, so help is just a few steps away for anyone who needs it.
“Women [with drug abuse problems] are already ashamed,” Whitecrane says. “We create a welcoming environment. Instead of sending patients to another building, I just walk them right over to the social worker or substance abuse counselor.”
The clinic staff set the criteria for referral to the program. Any pregnant patient who misses an appointment, admits to previous drug use or delays prenatal care, for instance, undergoes a drug screening test. Patients who test positive are then referred to the Special Care Clinic.
The program also utilizes other evidence-based practices, such as drug contracts and incentives for staying drug-free. A group called Mothers Lifeline provides gift certificates for the mother and items for the baby. The gifts help make the patients feel special and serve as incentives to stay healthy. And the items for the baby make the pregnancy feel more real to the expectant mothers, giving them further incentive to take care of themselves.
Healing and Hope
Whitecrane says she has had to learn about methamphetamine in the last few years as the incidence of meth abuse began growing among her patients. She believes there is hope for these mothers and their children. “We often see these things turn around,” she notes.
Most of Gutierrez’s patients with addictions have alcohol problems, but she is seeing a growing number of young people who abuse methamphetamine. An expert in pain management and addiction medicine, Gutierrez says meth addiction is difficult to treat because the drug distorts people’s judgment, making them overly confident or paranoid.
Gutierrez, whose grandfather and great-grandfather were American Indians, began working in Indian Country 27 years ago after she joined the U.S. Public Health Service. “I’ve learned more from my patients than they have learned from me,” she declares. “In Western medicine, we impose healing from the outside in. In Indian Country, people heal from the inside out. [Indian] people believe your health starts with spiritual harmony.”
She says she tries to motivate patients to get in touch with what’s inside them, and she meets them where they are. “You have to have a relationship with that person,” she explains. “I ask them, ‘What is missing from your life and what do you need?’ The trick is to appeal to a person’s will to live. That’s the art of medicine.
“The saddest thing is to see a patient who doesn’t want to help himself and has decided to continue with the addiction,” Gutierrez continues. “When a person comes to me like that I can’t help him. What I try to do for those patients is keep the door open.”
But for other patients battling meth addiction, victories are occurring. Gutierrez knows of many people who, suffering from addictions, “went to the bottom of the pit and stared death in the face” and then chose to recover. “When those people emerge from that abyss,” she says, “they have incredible wisdom and personal dignity, and they’re able to help others [who come after them].”