“There is definitely a need for more minority researchers,” asserts Ida Spruill, RN, MSN, MSW, of the University of South Carolina Medical College in Charleston. “When I try to identify mentors and colleagues, they are few and far between. I have to think in terms of someone outside my city or state because we just don’t have a large enough cadre of minority nurse researchers in this country.”
Spruill is the coordinator for Project SuGAR (the Sea Islands Genetic African American Registry Project), a community-based research study focusing on African-American families affected by type 2 diabetes. She got involved with the project six years ago when she met W. Timothy Garvey, MD, the study’s principal investigator. “He came to me at my previous job and asked me to help him find a black nurse to get involved in the project,” she says. “I looked around and thought of people who might be interested—but I was interested myself! I found out later that he had actually been told to talk to me about getting involved.”
Since then, Spruill has not looked back. “I enjoy research. The challenge intrigues me,” she explains. “Back when I was in nursing school, research was an area I knew little about. I never considered going back for my PhD. Now I’m staying with Project SuGAR until it ends, and then I’m starting a doctoral program.
“It’s important for minority nurses to get involved in researching minority health issues,” Spruill continues. “We need research that represents the community. That’s one reason Project SuGAR has been successful. The research questions, outcomes and interventions are different when they are determined by someone who is a member of that same population, someone who brings a unique insight. Sometimes in the past, pieces of the puzzle have been left out because of a lack of cultural understanding. I’m not saying that Caucasian researchers don’t do a good job, but African Americans start with an advantage when researching an African-American population.”
Asking the “Why” Questions
Spruill’s route into a research career was unusual in two ways. She doesn’t have a doctorate—yet—and she was not originally based at a college or university—the usual prerequisites for researchers. But when Garvey approached her for the SuGAR Project, she already had a research role model: Dr. Linda Burnes Bolton, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai Health Systems in Los Angeles.
“She sparked my interest in research,” Spruill explains. “I met her through the National Black Nurses Association. She was one of the first people who helped me see that African Americans can go into research.” Talking with Bolton also changed Spruill’s whole perception of what research is all about. “Prior to meeting her, my idea of research was dusty books and working alone in a room. She gave me an understanding of what is really involved.”
Spruill’s attraction to scientific investigation was also sparked by the fact that she had unanswered questions about minority health issues. For her, research was the way to find answers.
Wanting to know why things happen is an essential trait of any good researcher, agrees Karen D’Apolito, PhD, RN, assistant professor of Nursing at Vanderbilt University in Nashville, Tenn. D’Apolito, who is African American, got her start in the field by “wanting to validate our practice through practice-based research in neonatal nursing.”
“I first realized that I wanted to do research around 1985,” she says. “I had received my master’s degree four years earlier and was working as a clinical specialist and nursing educator. But I wanted to do more. That was when I got involved in research and decided to earn my PhD in nursing.”
How can you know if research is the right career choice for you? The key is knowing your ultimate goals, D’Apolito advises. She recommends that potential nurse scientists consider the kind of contribution they want to make to the profession and whether they are geared more toward being a practitioner or looking inquisitively at health care issues. As she explains, “People who question care-giving procedures are the ones who are best suited to improve them.”
D’Apolito is alert to students who show an interest in research. “They ask the ‘why’ questions,” she says. “And they don’t accept answers like ‘that’s just the way we do it.’ They want to know why one way is better than another. Potential researchers like to read the literature and are open-minded to discovering more than one way to do something. These are the people who are likely to become good scientists.”
At Delaware State University in Dover, Del., Nursing Department Professor and Chair Mary Watkins, PhD, RN, also watches for potential researchers among her students. “They need to be critical thinkers,” she says. “They must be able to analyze and apply information, and they need to be willing to earn a doctorate. Educators can tell early which students show a talent for research. When our students take the Introduction to Research course, we can tell from their interest level. Research is very time-consuming. You have to have commitment to become a researcher.”
Her own motivation is central to the research process. “I became a researcher because I realized that it is part of what I need to do to gain and create knowledge.” Watkins’ dissertation focused on decision-making among nursing students at the diploma level. Today she continues to conduct research into decision-making processes in health care.
“Being a nurse researcher is such a time-consuming venture that you need to establish a research agenda for your career,” Watkins emphasizes. “You will usually continue to study in the same general area over time, so the earlier you identify your area of interest [such as cancer, mental health, etc.], the more opportunity you’ll have to get substantial research done during your career.”
Ivy-Covered Halls vs. Clinic Walls
For Watkins, academic life—rather than clinical practice—is the environment of choice. “From the outset of my career, I wanted to teach,” she recalls. “My mother was a teacher and my aunt was a nurse. Mother and I had a debate. She said, ‘You don’t want to be a nurse; you want to be a teacher.’ Then as I developed in nursing, I saw I could teach and do research, too. I’ve been tempted to leave academe and go into the clinical setting as an administrator, but I enjoy sharing what I know.”
Making the choice between clinical research and academic research can be difficult. Both have their pros and cons. From the salary standpoint, “clinician researchers make much more money than academicians,” Watkins notes. “Universities have always paid less. That’s why there is such a shortage of nursing faculty. If I try to recruit a potential faculty member from a hospital, they are probably making 30% more than I can offer them. But the love of teaching does draw some nurses into academia.”
Clinical work does not have all the advantages, though. Getting summer off with time to refuel is a persuasive factor in favor of teaching. On the other side of the equation, however, young faculty members sometimes struggle to balance the demands of teaching, research and providing service to the university or community by serving on committees or doing volunteer work.
But regardless of which setting researchers choose to work in, “there are many opportunities for minority nurses,” Watkins says. “For the underserved minorities in the U.S. population, there has only been limited research on their health problems and needs. Yet they suffer from heart disease, cancer and many other diseases at rates higher than the Caucasian population. More funding would help, but it doesn’t seem to be getting easier for minority nurses to get funding.”
And I Can Prove It!
“I got started in research because I’m nosy,” says Carla S. King, PhD, RN, who is CEO of Carla King and Associates in Boulder, Colo. “I’ve always been interested in getting better care for poor people. In nursing school I learned a lot, but I felt that there had to be a better way to address these concerns. I wanted to make a difference.
“I found out that my opinions and ideas counted—but they had much more credibility when I could back them up with documentation. That made them more than just Carla’s ideas or opinions. I could say: ‘This is what I thought and here is the objective information I collected, and this is what I want to change.’”
As the head of her own business, King, who is African American, does health care consultation, programming and outcomes research. She sees a growing interest in research by nurses in clinical practice. “Nursing, as a profession, needs to do more research in order to demonstrate our position as experts and to document our effectiveness,” she says.
“There are many types of research that need to be done,” King adds. “Clinical nurses need to be a part of it as well. They may see things in their work environment that could be changed to improve patient care. Sometimes research comes from seeing things you want to improve, but you need hard data to document the need for that change. Or clinical nurses may have administrative concerns. They need to present data to show how doing something differently would be better for the hospital. Research isn’t just for the academicians.”
What’s the best way to get started in a research career? Daniel O’Neal III, RN, MA, CS, chief of the Office of Science Policy and Public Liaison at the National Institute of Nursing Research, offers this advice: “Collaborating with someone and doing a piece of their research work [on a project] is the best way for a beginning nurse researcher to get involved. Colleagueship and cross-age cohorts are part of the game—the established researchers are always helping the new group of researchers. In addition, going to conferences and association meetings can help you get started.”
Publish or Perish
Although the exact number of minority nurse researchers is not known, published research studies focusing on minority health issues are on the increase. “One interesting thing about being an editor is that you rarely know the ethnicity of authors, but about 10% of the research I see is minority-focused,” says Molly C. Dougherty, PhD, RN, FAAN, editor of the journal Nursing Research.
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Dougherty, who is also the Francis Hill Fox Professor of Nursing at the University of North Carolina at Chapel Hill, believes that minority health is definitely a growing area of research. “It is being driven by the National Institutes of Health’s emphasis on research in this area and the increasing amount of work being done to address racial and ethnic health disparities.”
Dougherty says the majority of research articles submitted to her journal come from nurse researchers at universities. Nurses in clinical practice tend to be co-authors. “Academic life is the primary way nurses get into research,” she says. “But today there’s a growing emphasis on programs that prepare nurses to manage clinical trials—at medical schools, health science centers and drug companies.”
Judith Graves, PhD, RN, FAAN, sees nursing research on the upswing from her vantage point as managing editor of the 1999 Directory of Nurse Researchers. “There are now more nursing researchers than ever,” she says. “When we compiled our first edition 15 years ago, there were only 500 or 600 researchers. Now we have 12,000 nurse researchers registered, and I estimate that this is only about half the actual number in the U.S. Most of them are housed in academe—it’s very difficult to get funding if you are not. Even private funding sources do not seem to fund people without an academic base. Universities provide the environment that supports research.”
Though the Directory of Nurse Researchers does not record researchers’ race or ethnicity, Graves agrees that minority-focused research is on the rise. “The trend toward more minority health research started about 10 or 12 years ago,” she notes. “Nurses are more aware of the need for cross-cultural knowledge, and more minorities are going into doctoral programs and becoming researchers.”
Five Ways to Develop More Minority Nurse Researchers
Last June, 27 minority nurse researchers and leaders of minority nursing associations met in Bethesda, Md. to participate in the invitational conference “Minority Health Research Development for Nurse Investigators.” This history-making event was sponsored by the National Institute of Nursing Research (NINR), the National Coalition of Ethnic Minority Nurse Associations and the National Institutes of Health (NIH) Office of Research on Minority Health (ORMH). One key issue the group addressed was how to promote career development of minority nurse scientists. Here are their recommendations:
• Grantsmanship training. Training on how to prepare grant proposals should be made more readily available to minority nurses. Special programs, such as the NINR Summer Institute “Research Training: Developing Nurse Scientists,” can play a valuable role in career development.
• Research training. NINR should evaluate its pre- and post-doctoral research training programs to determine factors associated with successful research careers. NINR should continue to provide special career development opportunities for minority nurse investigators and should consider developing short-term fellowship programs to provide additional training. A centralized database listing federal and non-federal research training opportunities is needed.
• Funding. NIH should increase the availability of grants of all kinds, including start-up funding, for minority researchers. NIH should consider developing a special funding mechanism for enlisting community leaders as research collaborators and should develop a minority R01 [a grant proposal submitted by an individual researcher] as a mechanism for minority scientists. NIH should develop a mechanism to track submissions of grant proposals and funding of minority investigators.
• Mentoring. Mentoring is key to the development of minority nurse researchers. A mentors network for minority nurse researchers should be established. NINR, the National Coalition of Ethnic Minority Nurse Associations and the ORMH should work together to establish a database of researchers interested in working as mentors. Schools of nursing should commit to building research capacity among minority nurse faculty and should provide mentorship opportunities for these faculty members. Schools should also provide support resources and an environment that maximizes the potential for nurse scientists to succeed.
• Peer review. NINR and the National Coalition should identify talented minority researchers to act as reviewers for NIH study sections. These reviewers could also serve as role models for other nursing professionals and would champion nursing research and minority health issues. Peer reviewers should incorporate criteria to address the participation of minority investigators. In addition, minority nurse investigators should be involved at all levels of decision-making for funding decisions.
It doesn’t take a PhD to figure out why the nation’s nursing schools urgently need to develop more faculty members in general and more minority faculty in particular—you just have to do some simple math.
First of all, according to the American Association of Colleges of Nursing (AACN)’s most recent survey of instructional and administrative faculty in baccalaureate and graduate nursing programs, the average age of full-time doctorally prepared faculty in 1999-2000 was 50 years. This breaks down into an average age of 49.5 for assistant professors, 52.8 for associate professors and 55.7 for full professors. As today’s baby boomer nurse educators continue to retire at a rapid rate, not enough new faculty are coming in to replace them.
Secondly, despite the ever-growing racial and ethnic diversity of the U.S. population, the vast majority of nursing school faculty is still overwhelmingly white. The AACN survey reports that 91.2% of all full-time nurse educators are Caucasian, while only 5.4% are African American, 1.3% are Hispanic, 1.4% are Asian, 0.4% are Native American and 0.2% are Native Hawaiian or Pacific Islander. Furthermore, of the 8.8% of nursing faculty members who are minorities, just 9.3% are full professors and only 32.4% are tenured.
Clearly, there is a tremendous need for more nursing faculty of color, especially at institutions that are actively trying to attract a more culturally diverse student population. As a result, positions in the field of teaching and academia are becoming an even more attractive career alternative for minority nurses than ever before. Because colleges and universities across the country are fighting over the precious few minority faculty who are out there, these educators can generally have their pick of universities, areas of the country in which to live and fields of study.
A career in education can be both an extremely challenging and highly rewarding experience. How can you tell if becoming a faculty member is right for you? Here’s what some minority nurses who have chosen this career path have to say.
Teaching is Just the Beginning
The first thing to keep in mind about academic careers is that faculty duties involve more than just teaching. Nearly all colleges and universities also require their educators to conduct research and perform service to their school, the nursing profession and the community.
To be successful in academia, nurse educators need to do more than just the basics, believes Cynthia Flynn Capers, RN, PhD, dean of the University of Akron College of Nursing in Akron, Ohio. “You must have a real love and commitment to teaching and learning,” she says.
“Nursing schools expect you to join nursing organizations and attend meetings that will give you a voice in the profession,” continues Capers, who is African American. “And while serving as an officer or committee chair for these organizations is not required, most nursing schools consider it an added plus.”
Nursing faculty are also expected to assist their college or university by joining campus committees, participating on task forces and advising and recruiting students.
Pao-Feng Tsai, RN, PhD, assistant professor in the College of Nursing at the University of Arkansas for Medical Sciences, serves on the department’s research committee. “I can choose from a variety of committees,” she says. “I need to participate at both the college and university levels. In addition, I must attend professional conferences and be a manuscript reviewer. If possible, I also hope to become an officer in a professional association.”
While Tsai spends both time and energy on the service aspect of her faculty position, it occupies far less of her attention than the other two components—teaching and research. “I probably spend a total of one to two weeks a year on service,” she comments.
But for faculty members at some other educational institutions, service is a bigger part of the picture. Every week, I do some service activity,” explains Betty Chang, FNP, DNSc, FAAN, professor at the UCLA School of Nursing in Los Angeles. “In our faculty, everyone has at least two committee assignments at the university, but I’m a senior faculty member, so I’m on even more committees.”
In addition to committee work at the university, Chang is active on an American Academy of Nursing committee, where she reviews manuscripts. “If you are part of an organization, you cannot help but be involved,” she says.
Even though teaching and research take most of her time, Chang feels her service activities are extremely important as well. Her advice to nurses considering an academic career is: Be prepared to work hard. “I work at my office and at home, seven days a week and many evenings,” she explains. “In the summers when I am not teaching, I am conducting research and publishing the findings.”
On top of all this, faculty members are also expected to do community service, says Capers. “Typical community service includes giving health education seminars, serving on boards and using your expertise to benefit the health of the community.”
“I Just Knew Teaching Was for Me”
Although their career clearly involves a lot of hard work, most nurse educators are passionate about the important impact their work has on the nursing profession. “Teaching is more demanding than I first thought it would be,” states Duck-Hee Kang, RN, PhD, assistant professor at the University of Alabama at Birmingham, “but it is also more exciting. I get excited when my students get excited. I help them learn to set high goals and always aim for quality work.”
For those students who hope to follow in her footsteps and become educators themselves, “I tell them that being a faculty member is a commitment to the nursing profession,” Kang asserts. “They start learning how to teach by observing teaching styles and volunteering to work with a faculty member. This helps them learn that teaching is more than just what goes on in the classroom—it also includes all the preparation that happens first.
“I just knew teaching was for me,” she adds. “It’s a way to make a contribution to the coming generations by using my experience and helping students learn.”
At Coppin State College School of Nursing in Baltimore, one of the nation’s Historically Black Colleges, Dr. Earlene Merrill, assistant dean of nursing, recently participated in a training session focused on the challenges of teaching students in the 21st century. “We talked about creating an exciting classroom setting to keep students motivated and involved,” she says.
More so than in previous generations, today’s student nurses want to be self-directed and to make their own decisions, Merrill believes. This creates a challenge for faculty members, who must develop a teaching pedagogy that helps students become both self-directed and successful.
“Teaching is much more difficult than it looks,” she points out. “It entails more work than many suspect when they begin.”
Merrill also emphasizes that nurse educators have to know how to maneuver through the academic setting to obtain the resources they need, such as teaching supplies, secretarial help or manageable class sizes. “Sometimes administrators do not understand what educators need,” she says. “I tell my students that in teaching, patience is rule number one and persistence is rule number two.”
What It Takes
In recent years, the health care industry’s severe shortage of hospital nursing staff has also begun to negatively impact the development of future nursing faculty. In some cases, schools of nursing have been forced to put more emphasis on their clinical nursing programs, while academic tracks that prepare students for teaching careers were neglected or even cancelled altogether
Miguel da Cunha, PhD, a professor in the Department of Nursing to Target Populations at the University of Texas School of Nursing in Houston, saw this happen at his institution. “We had three different tracks at the master’s level: administration, teaching and clinical,” he explains. “There has been such a need for clinicians that we cancelled the teaching and administrative tracks for awhile. But now there is a reemergence of interest in education and we are reinstating them.”
When students ask him about becoming a faculty member, da Cunha is encouraging but realistic. “There are not many perks or company cars,” he tells them. “Our perks are what we get back from the students and our own personal satisfaction.”
Da Cunha compares academics’ triple duties of teaching, research and service to a lopsided three-legged stool: In terms of professional recognition, teaching is the short leg. “Research tends to get all the glory,” he maintains.
He has reason to know both sides. Originally in research, he switched to the classroom in the 1970s. Since then, da Cunha has earned three John P. McGovern Outstanding Teaching Awards.
He personally defines outstanding teachers as people who love their profession, are committed to continuously learning and who share their knowledge and techniques in peer review journals. “Teaching and scholarship have to be complementary,” he says.
Advising, too, is a necessary component of a successful academic career, da Cunha adds. “Advising is an important part of teaching—it is mentorship. Teaching is not limited to what you do in the classroom. Advising means guiding students through their education process. I keep in touch with my students throughout their program, advising them on strategies to improve their achievements. That’s part of the joys of teaching. Students keep me rejuvenated.”
Mentoring and advising is particularly important for minority students, who can sometimes feel isolated or slip through the cracks in predominately white nursing schools. Minority professors can serve as empowering role models for students of color, letting them see that they too can become successful nurses, educators and researchers.
The Rigors of Research
Leonie Pallikkathayil, RN, DNS, winner of the University of Kansas Chancellor’s Award for Distinguished Professorship, is associate professor at the University of Kansas Medical Center School of Nursing in Kansas City and is extremely active in research. One of her most recent projects was a study funded by the National Institutes of Health on fatigue in healthy individuals.
Pallikkathayil advises master’s-level students who plan to become nurse educators to “do a master’s thesis or a research project,” to prepare them for the research component of a faculty member’s duties. “It’s important to get first-hand experience in the research process,” she says. She also recommends that students work with faculty as research assistants to “get experience in being part of a team and to observe different aspects of research work.”
Being a successful researcher, and therefore a successful nurse educator, requires several key qualities, Pallikkathayil believes: “It takes energy, enthusiasm, imagination, creativity, patience and persistence. Plus, you have to be able to balance the demands of teaching, research, service and practice requirements and still have a life!”” She also stresses the ability to deal with disappointment, because of the amount of rejection that goes along with research. “You won’t get funded each time you apply for a grant,” she explains.
Nursing professors are often quick to recognize a student’s inclination toward research. When Bertha Davis, RN, MS, PhD, FAAN, assistant dean for research at Hampton University’s School of Nursing in Hampton, Va., encounters a student who is a critical thinker and shows curiosity about why and how things happen, she knows he or she would make a great researcher.
“When research-oriented students create care plans or research papers, they are really detailed about rationales and they question information,” says Davis, who is also a professor at the historically black university. “They look for alternative points of view in the clinical setting. When students possess those qualities, I want to see them continue their education.”
Educators such as Davis are eager to develop more minority nurse research professors, because of the enormous need for culturally sensitive research on diseases and health risks that disproportionately affect people of color. “I believe all faculty members should review their notions about cultural appropriateness to help create culturally competent research practices,” Davis states.
However, she cautions, “Just because a faculty member is a minority does not mean that they are sensitive to all people in their culture. There are many subcultures, and we have to learn what research subjects’ specific environments are like.”
Packaging Your Career
Back when Maria Warda, RN, PhD, was a health care administrator, she discovered she had been preparing to move into a career in academia—without even knowing it. Her experiences in a variety of work environments and countries, and the joy she felt in helping new nurses develop themselves professionally, made her want to use this passion to teach nurses in a college or university setting.
“That’s when I decided to return to school for a doctorate,” says Warda, who is now assistant dean of diversity enhancement and academic services at the University of California, San Francisco, School of Nursing. “I believe good faculty members must have a passion for lifelong learning, as well as a real commitment to enhancing the learning experiences of their students.”
Teaching can be particularly rewarding for minority nurses, adds Warda. “Minority nursing faculty members have different perspectives [than majority faculty],” she says. “It’s important for us to bring those perspectives to the classroom and share them with students.”
Faculty Salaries 101
A common objection to careers in academia is that faculty members earn lower salaries than nurses in clinical or administrative positions. But is this perception really true?
The American Association of Colleges of Nursing (AACN) reports that college and university nursing professors with doctorates earned an average of $68,779 for the 1999-2000 academic year. What’s more, that figure represents an increase of 3.8% from the previous year.
Even on lower rungs of the academic ladder, faculty earnings compare more favorably with clinical nursing salaries than you might think. Here is the AACN’s breakdown of salaries by rank for the academic year 1999-2000:
Professor
$68,779 (With Doctorate) $62,294 (Without Doctorate)
Associate Professor
$56,585 (With Doctorate) $46,734 (Without Doctorate)
Assistant Professor
$48,738 (With Doctorate) $41,870 (Without Doctorate)
It is certainly no secret that American Indians suffer disproportionately from many serious health problems, including diabetes, cancer, AIDS and substance abuse. Nor is it news to most nursing professionals that more research into the causes of these health disparities is urgently needed in order to develop effective, culturally competent prevention and treatment programs. But despite this common knowledge, American Indian populations and their culture are familiar yet foreign to much of the nation’s nursing community.
Because Indians are severely underrepresented among the ranks of nurse scientists, many non-Indian nurses have conducted research in Indian communities–or have attempted to do so. The key factor in determining whether such research projects will be successful or fruitless is the nurse’s awareness of, and ability to overcome, the unique challenges involved in working with Indian populations. Many of these challenges relate specifically to the issue of conducting research in a manner that is culturally sensitive to Indian communities’ needs.
The first challenge researchers must meet is that of establishing trust and proving their commitment to conducting research in a culturally respectful way. Many Indian tribes are distrustful of outsiders and do not welcome researchers into their communities. Furthermore, Indian communities have been the focus of hundreds of research studies over the years but have not always had the opportunity to benefit from these projects and their findings. Because of this overuse of Indian communities, many tribes have become closed to non-Indian researchers.
Nurse researchers need to understand that it takes time to build trust. Sometimes, getting a research project started in a tribal community can take one to two years–or more–of preparation before the researcher can even begin the study. Therefore, researchers not only need to be committed to overcoming barriers of distrust but must also be willing to commit time to getting access to the Indian community.
Getting It Right
There are several culturally sensitive steps a researcher can take when preparing to conduct a study in an American Indian community. The first step is to identify what type of Indian community it is–a reservation, a non-reservation community, an Indian nation, a tribe, a band, a federally or non-federally recognized tribe or an urban community.
This knowledge is important because there are cultural and historical differences between these various types of communities, such as languages, degrees of assimilation, means of identifying tribal members, and sustained cultural practices, to name a few. There are also differences in community size, tribal governance and the tribe’s relationship with the U.S. government. Researchers must be familiar with these distinctions in order to address the community and its members knowledgeably and appropriately.
For example, an Indian reservation is a self-contained tribal entity with its own government, governing rules and land base, while a non-reservation Indian community–such as those in Oklahoma–may have a tribal government but not the land base. The terms “Indian nation” and “tribal nation” refer to the largest Indian communities, while “band” usually refers to smaller groups of people within one tribe–e.g., the Ojibwe tribe has many bands, and the governing structure for each band may vary. Therefore, members of an Indian nation may be offended if an outsider calls it a band or a tribe, and vice versa.
Researchers also need to consider the region of the U.S. in which the Indian community is located–e.g., Southwestern, Southeastern, Northwestern, Eastern, state of Oklahoma or state of Arizona. Each region has had its own impact on the history and development of the Indian communities it contains.
For example, in Oklahoma during the territorial days, the state was made up of many Indian reservations. But in the early 1900s these reservations were taken away from the tribes, and each enrolled Indian person was instead given a parcel of land. This change in the land base dramatically altered the way of life for Oklahoma Indians.
In addition to learning as much as possible about an Indian community’s history, structure and culture in advance, a researcher preparing to conduct a study in that community may also want to visit the area. Much can be learned from visiting the community’s cultural center, attending a public Indian event in the community, visiting a historical Indian site, talking to the local Indian people and becoming familiar with the local customs.
When visiting the Indian people, a researcher who is culturally sensitive will ask them how they prefer to be addressed and how they want to be identified. For example, members of the Navajo Nation may prefer being identified as “Diné” rather than “Navajo.”
It’s also important to let the Indian people reveal information about their community in their own way and in their own time. If you ask them direct questions, you might not get answers. Indian people believe in developing a oneness of spirit with another person before information can be exchanged.
Working With What You’ve Got
Another challenge a researcher may need to overcome is the limited availability of resources in an Indian community. Because many tribal communities are poor and do not have economic development, the people who live there generally lack financial resources as well as adequate housing, transportation, sanitation, clothing or food.
Furthermore, many Indian communities are located in remote and rural areas of the country where access to necessary resources and services is severely limited. In the Deep South, for example, there are many small Indian communities in rural areas where there is no public transportation and no emergency services, hospitals, clinics, or physicians nearby to care for the Indian people. These people must drive long distances to receive health care–if they even have a car.
When conducting a research study, these kinds of factors can influence the outcome of the project. For instance, the Indian people may not even be able to arrange transportation to participate in the study. You will have to bring the study to them.
Difficulty in obtaining a large enough sample size is still another obstacle that can prove frustrating for nurses who want to conduct research studies in an Indian community. The largest tribe in the U.S. is the Navajo Nation, which has over 250,000 enrolled members, followed by the Cherokee Nation with around 222,000 enrolled members. Most tribes, however, are much smaller in size, averaging only a few hundred or thousand tribal members. As a result, American Indians are often not included in studies examining significant health problems like breast cancer and lupus, because the sample size is too small to be statistically valid.
It is not always easy to find a solution to this problem. Some experts suggest grouping several small tribes together to increase the sample size, while others argue that this method is not always culturally appropriate and that tribes do not like to be “lumped” together in this way. Another possible approach would be to explain the reason for the small sample size and adjust the statistical significance accordingly. For example, if 50% of the people in a tribe are diabetic, this is a significant finding even if there are only 250 tribal members.
Creating Co-Ownership
Because of the negative research experiences they have had in the past, many Indian communities are now demanding more respect from outside researchers, as well as a greater sense of co-ownership in the study before, during and after it is conducted. To be culturally sensitive, nurse researchers must strive to develop a more “equal” partnership with the tribe.
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Traditionally, many researchers have only wanted tribal communities to assist with recruitment of subjects and nothing else. Once the data was collected, the researchers never returned or followed up with reporting the findings back to the community. The tribes did not know the outcomes of the studies. The researcher benefited from the study while the tribe received few, if any, benefits from its members’ participation in the project.
Tribes are also raising questions about who owns the data from a research study conducted in their community and are demanding more control over how the data is handled. In some studies, the findings were not only published without any input from the tribal community but also published in a way that reflected negatively on the tribe.
To cite just one example, a researcher who conducted a study on health problems occurring in an Indian community in the Midwest did an interview with a local newspaper about her findings. She did not get an opportunity to review the reporter’s article before it was printed. When the article appeared, it contained disparaging and factually inaccurate comments about the tribe’s cultural traditions and how they allegedly contributed to the Indians’ health problems.
In addition, much of the research that has been conducted with Indian populations has tended to put too much emphasis on the “culture of poverty” in tribal communities. By focusing on the effects of poverty on Indian peoples’ way of life, many researchers have overlooked the strengths of the Indian community. As a result, a growing number of tribes are insisting that researchers focus on tribal and cultural strengths instead of on health deficits.
For instance, many studies have been conducted about the breakdown of American Indian families but very few have explored the positive aspects of Indian family life. One notable exception was a recent study on Indian parenting in which the researcher described how Indian mothers parented in such a way that the harmony (natural development) of their children’s lives was promoted through passive forbearance (the Indian pattern of care).
The Indian mothers did not parent in a way that controlled their children’s development but rather in a way that enhanced natural development through unobtrusive, respectful behaviors like listening, observing and being an example to others. In other words, the researcher chose to focus on the cultural patterns of parenting instead of on how poverty impacted the parenting.
Because of these kinds of experiences, tribes that participate in research studies want more of a say into the interpretation and dissemination of the findings. A researcher may need to include the tribe in the analysis of the data and get tribal approval for publication of the findings. This kind of tribal involvement can be written into the research proposal.
Finally, many Indian communities have become more “research-savvy” in order to better protect their interests. Many tribes now have their own Institutional Review Boards (IRBs) to which potential researchers must submit their proposals. Nurses who wish to do research in a particular Indian community need to become familiar with the appropriate procedure for obtaining the tribe’s permission to conduct the project. You may need to not only get the tribal IRB’s approval for human subjects but also get approval from either the tribal chief or tribal council.
In one research study conducted with a Southwestern tribe, the researcher had to first get approval from two tribal subcommittees and then go before the 15-member tribal council before approval for the project was given. The entire approval process required five visits with the tribe, and it took six months before the final decision was made.
Sometimes tribes will “barter” with researchers to ensure that both sides benefit equally from the partnership. For example, members of one small tribe in the Deep South successfully negotiated an arrangement in which the researcher agreed to assist them in writing an economic development grant in exchange for their participation in the study.
Playing by the (Cultural) Rules
In summary, nurse researchers must remember two important ethical principles when conducting studies in American Indian communities. The first is right to informed consent. The tribe needs to know the purpose of the research, who will benefit from the research, and how the research will be conducted with appropriate tribal input.
The second principle is do no harm. The researcher has an ethical duty to protect the tribal community by not violating cultural norms, by not publishing findings without approval from the tribe and by taking measures to protect the Indians’ culture. By following these rules of cultural sensitivity and respect, nurse scientists will greatly increase their chances of successfully overcoming the challenges of conducting much-needed research on American Indian health disparities.
Deborah Dawson, MSN, RN, is a special nurse with a very special career. As a clinical trials research nurse for the Diversity Enhancement Program (DEP) at Ohio State University’s Arthur G. James Cancer Hospital and Richard J. Solove Research Institute–known as The James–she is making a difference in the lives of many people who, until recently, were often overlooked: minority cancer patients.
Dawson, who is African American, says she wanted to be a clinical trials research nurse because it would enable her to enhance communications and cultural relations between The James and local minority and medically underserved communities in the Columbus area.
“Caregivers who are of the same race or cultural background as minority patients are often able to establish a greater level of trust with them,” she explains. “These patients often feel more comfortable when they can talk with someone who understands their background, customs and beliefs. [In my role] within the DEP, I am able to work with these patients and establish that trust. It’s extremely rewarding.”
The James launched the Diversity Enhancement Program in 2003 to raise awareness of cancer prevention, early detection and treatment in minority communities, with an emphasis on increasing minority participation in clinical trials. One of the program’s early objectives was to recruit more minority staff like Dawson to help patients feel more welcome, at ease and understood.
Historically, cancer patients of all races have sometimes been reluctant to participate in clinical trials–either out of fear of the unknown or a concern that they may be used as “human guinea pigs.” These fears are often magnified among minority patients, who may feel that majority health care personnel do not understand their culture and specific needs.
People who have these misgivings may not realize that clinical trials can offer improved outcomes for cancer patients. This is especially important for people of color, who are disproportionately affected by this disease. For example, according to the American Cancer Society, African-American men have a 20% higher incidence and a 40% higher death rate from all cancers combined, compared with Caucasian men.
The DEP is a multifaceted initiative that is working to reduce minority cancer disparities on several fronts. It has five objectives:
1: Recruit Minority Staff Members
Many health care professionals, like the public in general, tend to have a negative perception of oncology and are often reluctant to choose a career in this field. People tend to link oncology with death and sadness instead of focusing on the research and other programs that are improving the quality of life for cancer patients.
To change these attitudes, DEP staff members work with health system recruiters and students in local health care education programs to improve their perception of oncology and to emphasize the opportunities that exist within this field. Staff members also mentor student nurses through the Columbus Black Nurses Association as a means of sharing their enthusiasm for cancer nursing.
Bringing culturally diverse nurses into the fold is mutually beneficial, according to Melissa Lowe, nurse recruiter at The James. “While nurses who share cultures with minority patients can help put patients at ease, the DEP’s mission also presents a unique opportunity for nurses,” she says. “Nurses with a special interest in reaching out to minority groups find working with the program very fulfilling.”
2: Promote Cancer Awareness and the Benefits of Routine Cancer Screening
Because cancer can be so devastating, people naturally fear it–perhaps more than any other disease. They therefore are often reluctant to visit, or seek information from, any facility where cancer is diagnosed and/or treated. The DEP is working to remove the mystery and fear associated with cancer by communicating the advantages of routine cancer screenings, early detection and lifestyle changes throughout the community.
DEP staff members have made presentations at senior centers, public schools, local colleges and universities and to associations of medical professionals. Other outreach efforts have included a seminar series specifically designed for African-American men. The DEP successfully recruited seminar attendees through grassroots outreach to churches, social groups and African-American fraternities.
In addition, the DEP sponsors a monthly hour-long radio program, “It’s All About Health,” which airs on a local gospel station. Hosted by William J. Hicks, MD, medical oncologist and co-director of the DEP, the show addresses cancer-related topics, including cancer types, cancer prevention and screening. Dawson, a regular guest on the show, presents information about specific clinical trials and how individuals may participate, as well as the important roles research nurses have in the clinical trials process. On another station, the DEP sponsors “Medical Minute,” a series of 60-second cancer-awareness messages.
“We want to make the public aware that what works for Caucasian patients may not work for African Americans and other minorities–and vice versa,” says Dawson. “Data collected during clinical trials can help determine different patients’ reactions to specific drugs and methods of treatment and improve outcomes for everyone.”
Dawson has received many calls from listeners who have heard the radio program and want more information. The show has prompted people to seek more details about the trials, the criteria for participation, the length of the studies and how the research can benefit them. “The radio program has helped listeners to link names and personalities with The James,” Dawson adds. “It has been a great tool for communicating with the public.”
3: Provide Cultural Competency Training
To help staff members at The James better understand the unique cultural needs of their patients, the DEP provides cultural competency training to boost comfort levels and enhance communication among caregivers, their patients and patient families.
For example, it’s helpful for hospital dietitians to understand why many African-American patients add animal fats such as pork grease to their vegetables and greens during preparation. Even though the practice is unhealthy, this cooking method dates back to a time when slaves received the leftover ingredients that were not used to prepare their master’s meals.
While some topics, like the origins of dietary and other health-related customs, can be uncomfortable for some minority patients to discuss with health care providers, cultural competency training enables nurses, physicians and others to explore and discuss lifestyles and habits of people from diverse backgrounds so these professionals are better prepared to approach and discuss treatments and alternatives with their patients.
4: Accelerate Minority Enrollment in Clinical Trials
Clinical trials are discussed in every outreach program the DEP sponsors. For example, during Breast Cancer Awareness Month, staff members are often asked to present information to local church groups, women’s clubs and government organizations. The presenters always mention cancer clinical trials and the need for greater minority participation.
The DEP also has several ongoing outreach programs, such as monthly presentations to individuals at Maryhaven, an addiction treatment and mental health facility in Columbus. Although the main discussion may focus on a specific type of cancer, presenters will mention clinical trials as an opportunity.
The DEP’s “Grandma’s Hands” program also reaches out to minorities and medically underserved individuals. Funded by a grant from the Columbus affiliate of the Susan G. Komen Breast Cancer Foundation, “Grandma’s Hands” includes 10 volunteer grandmothers who have agreed to help present breast cancer awareness programs to women in their communities.
The idea of using grandmothers to communicate the clinical trial message originated from the words of a popular song that talks about the wisdom among the grandmother population and how these women can influence their families, friends and communities. During the “Grandma’s Hands” sessions, a DEP presenter talks about breast cancer, cancer prevention and the opportunity for cancer patients to become involved in clinical trials.
The presentation is followed by a group activity selected by the grandmother who hosts the session. One grandmother chose the activity of creating photo collages while another helped her group create quilt squares. “Grandma’s Hands” sessions are held in the hosting grandmothers’ homes, in participants’ homes, and at churches and other locations. The DEP has conducted these sessions, for example, at area schools and government offices. The DEP provides all invitations, snacks and any needed supplies.
In 2004, the DEP identified and educated 500 women through the “Grandma’s Hands” sessions. While the program has been targeted mostly toward African-American women, DEP planners hope to expand it to reach other medically underserved community segments.
The DEP has created educational tools for use in “Grandma’s Hands” sessions and other outreach programs. Participants receive awareness pins, designed by Ohio State University, that sport the red, black and green found in the flags of several African countries, along with pink to signify breast cancer awareness. Black represents the African people, red is a reminder of past bloodshed and green foretells the future and the hope represented by new programs that will help eliminate health care disparities.
These pins are great conversation starters. The program leaders ask participants to accept the pins with the promise that they will help spread the word about breast cancer prevention and the important role of clinical trials.
The James has also developed a video that staff members use to help recruit minority cancer patients for clinical trials. The video includes testimonials from several minority patients who have benefited from their participation in this type of treatment.
5: Encourage Researchers to Design Trials Specifically for Minorities
Many minority cancer patients are also suffering from other health problems, such as diabetes, high blood pressure, heart disease or kidney disease. Patients with these pre-existing conditions are usually ineligible for cancer clinical trials, which limits the number of minority patients who meet the criteria for this important clinical research.
Through regular communication, the DEP is encouraging researchers at The James to design studies targeted to patients who have health problems in addition to cancer. Developing protocols for patients with pre-existing conditions to participate in cancer trials would provide more opportunities for African Americans and other minorities to become involved in critical studies.
Planning for the Future
Although the DEP is still in its infancy, planning is underway to expand the program. For example, staff members are considering initiatives to reach more Latino, Asian and Native American populations. The DEP is also looking at ways to reach more African-American men through an existing program called the Men’s Health Initiative. This project will be expanded to provide education and screening information for all types of cancer to large groups of African-American men.
“Historically, the American health care system has not been set up to provide education to keep minority patients well,” Dawson says. “Education is an area where minority nurses and other health care professionals can really make a difference in communicating with minorities and the underserved in our communities and in helping to improve cancer outcomes for current and future generations.”
“I’ve always been interested in designing interventions that are targeted to improving the health outcomes of high-risk populations–particularly children, adolescents, pregnant teens and mothers,” says Luz Porter, RN-CS (FNP), PhD, a graduate professor at Florida International University School of Nursing (FIU SoN) in Miami. One highly vulnerable population about which she is particularly concerned are substance-abusing mothers (SAMs) and the approximately 750,000 babies who are born each year with drug addictions as a result of their mothers’ habits.
In 2003, Porter’s interest in developing an intervention program for these high-risk infants and mothers made history: She secured nearly $1 million in federal funding to conduct a pioneering four-year study that will examine the long-term effects of incorporating Infant Massage (IM) therapy as part of intervention and caretaking programs for SAMs and their babies. The grant, funded by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (Title V, Social Security Act), is the first of its kind in this area of maternal/child nursing research and one of the largest federally funded research grants generated by an FIU SoN faculty member to date.
According to Porter, who is an officer of the National Coalition of Ethnic Minority Nurse Associations and a past vice president of the Asian American/Pacific Islander Nurses Association, previous studies have shown that IM therapy has definite developmental benefits for drug-exposed infants. For example, massaging these babies helps increase their ability to maintain a functional, alert state. It also helps stabilize their heart rate and respiration, improving sleep, relaxation and the ability to cope with stress. Plus, brain scans of regularly massaged high-risk infants show more intricately developed neural pathways, which are critical to surviving and learning.
However, Porter’s landmark study, “Drug-Abusing Mothers: Infant Massage Parenting Enhancement,” goes one step further: It is the first to correlate the benefits of IM therapy as a technique for drug intervention on both mother and child. The study’s primary goal is to develop an effective intervention that blends IM techniques into a systematic Planned Enhancement Parenting (PEP) program. This approach is designed to not only assist recovering SAMs with the caretaking and nurturing of their infants but also to decrease their risk for drug relapses, parental stress and depression.
“Interventions that build upon the natural components of early mother-infant interactions are critical to reversing the adverse effects of perinatal drug use for the children and breaking the cycle of addiction for the mothers,” Porter explains.
The research, which will be conducted through the university, was launched in September 2003 and will run through August 2007. The study will recruit up to 270 SAMs with babies ranging in age from one to 12 months. The mother/baby pairs will be divided into three groups: one that uses the combined IM/PEP method, one using only PEP methods and one control group.
