According to the most recent U.S. Census, Hispanics are the nation’s largest and fastest-growing minority group, accounting for 13% of the total population. Moreover, that figure is expected to rise to more than 25% by 2050. Yet in many parts of the country, Hispanics continue to face substantial health disparities, including underinsurance, a lack of linguistically and culturally competent health care providers, and disproportionately high rates of serious chronic diseases such as asthma, diabetes, cancer and HIV/AIDS.
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In a nationwide effort to reduce these gaps, the Department of Health and Human Services (HHS) has launched the “Su Familia” National Hispanic Family Health Helpline (866-783-2645/866-SU-FAMILIA), a toll-free bilingual information center for Hispanic health consumers. Open to callers from 9 am to 6 pm Eastern Time, Monday through Friday, the helpline provides free, confidential health information in English and Spanish, as well as referrals to local health care providers and to federal assistance programs like the State Children’s Health Insurance Program (SCHIP).
Su Familia (Spanish for “your family”) is designed to give Hispanic individuals and families basic health information to help them prevent, manage and receive treatment for chronic health conditions. The helpline is staffed by bilingual health information specialists who can answer callers’ questions, refer them to one of over 16,000 local health providers (including community and migrant health centers) and provide bilingual fact sheets on a variety of health topics, including asthma, cancer screening, diabetes, cardiovascular disease, immunizations, HIV/AIDS and domestic violence.
Supported by HHS’ Health Research and Services Administration (HRSA) and the Office of Minority Health, Su Familia was developed and is operated by the National Alliance for Hispanic Health. The Alliance also provides two other bilingual helpline services: the National Hispanic Prenatal Helpline (800-504-7081) and the National Hispanic Indoor Air Quality Helpline (800-SALUD-12).
Many elderly people have moderate or severe asthma that has been underdiagnosed or undertreated, according to a recent study by Johns Hopkins University. The elderly also experience a decreased quality of life as a result of asthma, according to Karen Huss, RN, DNSc, a nurse researcher and associate professor at the John Hopkins University School of Nursing.
In Huss’s study of 80 senior citizens over age 65, published in a recent issue of Annals of Allergy, Asthma and Immunology, she found that two thirds of the participants had either moderate or severe persistent asthma caused primarily by elements in the home such as dust mites, mold and allergens from cockroaches, cats and dogs. Asthma medication was either not being used or being used improperly. These findings are particularly important for minority elderly, who are at a greater risk for asthma than Caucasians.
“Asthma is a significant, chronic problem in the elderly,” says Huss. “Despite the high prevalence, major allergens in the homes have not been identified. We conducted home visits to collect dust samples and evidence of other allergens. That is the first step in alleviating the problem.”
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Nearly 75% of elderly in the study tested positive to airborne allergens, and 53% were skin-test positive to at least one indoor allergen. Senior citizens were primarily sensitive to indoor allergens, and allergen levels in their homes were often high enough to place the elderly at risk for asthma complications.
“Our data also suggests that asthma in the elderly contributes to a decreased quality of life,” Huss notes. Those with more severe asthma reported more negative feelings about life in general, described their health as being poor and had a greater degree of impairment during daily activities. This finding implies that senior citizens with severe asthma are less likely to engage in domestic activities such as dusting and vacuuming, leading to higher allergen levels and ultimately exasperating severe asthma.
Few elderly persons take proper medication to treat their asthma, according to the researchers. One third of the elderly participants in the study were not taking inhaled steroids, the preferred method of treating asthma.
“It is critical that we first identify and control allergens in an elderly person’s environment in order to avoid asthma attacks,” says Huss. “Skin tests need to be done on elderly patients with asthma so they will know what to avoid. Once allergens in the home are reduced and medications that combat inflammation in the airways are introduced, then asthma severity in the elderly should decrease and the quality of life should improve.”
It’s probably the best working example of universal health care in America. It’s a system that provides millions of people with a widely comprehensive range of health and wellness services–everything from disease prevention programs to dental and optical services to hospital and ambulatory medical care. Its goal is to “ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaska Native people.”
It is the Indian Health Service (IHS) and it remains the nation’s largest employer of American Indian and Alaska Native nurses. But regardless of race or ethnicity, if you’re a nurse who has a strong desire to experience different cultures, work with medically underserved communities, fight minority health disparities and reap the benefits of a career that offers chances to advance to leadership roles, working for the Indian Health Service may be just the opportunity you’ve been looking for.
The Details
In 1921, Congress passed the Snyder Act, which established the Indian Health Service as the primary federal health care provider and health advocate for Indian people. It’s a role the agency has continued to play for 80-plus years, providing a comprehensive national health delivery system designed to elevate the health status of American Indian and Alaska Native people to the highest possible level and to encourage the maximum participation of tribes in the planning and management of those services.
Although Native tribes are sovereign nations, the IHS is a U.S. government organization operating under the Department of Health and Human Services (HHS) umbrella. Today, it cares for 1.6 million of the nation’s estimated 2.6 million Native Americans from more than 560 federally recognized Indian tribes and Alaska Native corporations coast to coast.
The IHS is an extensive system, divided into 12 regional areas, that encompasses 36 hospitals, 63 health centers, 44 health stations and five residential treatment centers in 35 states. In addition to these facilities, most of which serve American Indians who live on or near reservations, the IHS also has 34 urban Indian health projects that provide a variety of services. Some IHS facilities are managed by the tribes themselves with financial and administrative support from the federal agency. At others, all daily operations are completely managed by IHS.
Nurses hired at tribally operated facilities (“direct hires”) are considered employees of the tribe. If the nurse is recruited by the IHS to work at a federally operated facility, then he or she is a federal employee. In addition, some nurses who work for the IHS do so as officers in the U.S. Public Health Service Commissioned Corps, a federal program under the direction of the U.S. Surgeon General in which nurses work for local, state, federal or international health agencies in a variety of capacities. Generally, nurses in the Commissioned Corps tend to have more experience and education and receive an expanded benefits package.
According to IHS statistics, there are currently more than 2,500 nurses in the organization working in inpatient, outpatient and ambulatory settings. Additionally, the agency employs public health nurses and nurse educators to carry out its numerous health awareness programs, among other duties. Many of these campaigns are created with input from tribal and spiritual leaders to address a particular community’s specific health care and cultural concerns.
Of course, like any large health care system, the Indian Health Service also provides opportunities for experienced clinicians to move into management positions on local, regional and national levels. But it’s the challenge of working with a unique patient population in a specialized environment that many IHS nurses cite as the most rewarding aspect of their career.
The Need
Like other health care employers today, the IHS is struggling under the weight of a severe nursing shortage and the increasing financial burdens of doing business in the current economic environment, despite a proposed budget of $2.9 billion for fiscal year 2004.
“We have a 14% nursing vacancy rate right now, compared with the national average of 13%,” says Celissa Stephens, RN, MSN, acting principal nurse consultant and senior recruiter for the IHS national headquarters in Rockville, Maryland.
The reasons for the nurse staffing crisis within the IHS mirror those for the health care industry in general. Fewer young people are choosing nursing as a career, while at the same time, the current RN population continues to inch toward retirement age. But this second factor has had an even bigger impact on the IHS than on private sector nursing employers. “The average age of nurses in the IHS is 48 years old, which is even older than the national average of 43 years,” Stephens explains.
More specifically, the IHS reports that approximately 755 of its 2,500 nurses are 41 years old or older. Of those, 8% were eligible for retirement last year. Even more alarming is that another 20% will be reaching retirement in the next five years.
While skilled, experienced nurses are urgently needed throughout the IHS system, Stephens says some specialties are in more demand than others. “At the present time, the greatest needs are in the areas of emergency, operating room, ICU and obstetrics,” she reports. “We’re also interested in Certified Registered Nurse Anesthetists (CRNAs).” There are also many career opportunities open for advanced practice nurses and Certified Nurse-Midwives.
The People
“Everything you do [as an Indian nurse working for IHS], you can see it making a difference. You’re working toward a goal to improve the health of our families and communities,” says LaVerne Parker, RN, MS, an IHS nurse consultant in the Aberdeen Area of South Dakota and a member of the Turtle Mountain Band of Chippewa Indians.
Indeed, there seems to be a very strong connection between American Indian/Alaska Native nurses and careers in the IHS. The agency reports that approximately 66% of nurses working in the federal system or for tribally operated health care organizations are Native Americans. While this may be partially due to the fact that IHS has Congressional authority to give American Indians and Alaska Natives preference in hiring, working for the IHS also appears to be a traditional career path for many Indian nurses.
For instance, Parker grew up relying on the IHS as her own health care provider. When she became interested in a nursing career, IHS was foremost in her mind. “I always wanted to work with my own people,” she explains.
“There was never any doubt that I would be working for my [Indian] community,” says Lisa Sockabasin, RN, BSN, of her career choice as diabetes nurse coordinator for the North American Indian Center of Boston, an urban IHS facility in Boston, Massachusetts. “I saw so many health disparities among American Indian communities during my experience as a research fellow at Harvard Medical School, including cardiovascular disease, diabetes and cancer. I really wanted to work in preventing morbidity and mortality in our communities.”
While it may be a sense of community that brings Native nurses to IHS facilities, it’s the rewarding work and career advancement opportunities within the system that are keeping them there. Working for an IHS or tribal-run hospital or clinic is different than the “typical” nursing job in a number of ways. First and foremost, the patient population is almost exclusively American Indian or Alaska Native. Therefore, culture plays a very prominent role in health care delivery.
“There are so many different meanings of what good health is and how it’s perceived in so many different cultures,” says Sockabasin, who is half Patsanaquoddy Indian.
Culturally and linguistically, Indian tribes are by no means all alike, even though there may be some common threads among the different groups when it comes to health issues–such as high incidence rates of heart disease and diabetes–as well as general beliefs about health and illness, such as an emphasis on the use of natural remedies.
“You can’t make generalizations about the tribes because they’re all different,” emphasizes Stephens, a member of the Choctaw tribe. “It’s important at the local level that new employees are provided with culturally appropriate orientation to the tribal communities they will serve.”
Language can also impact health care delivery in Indian communities, especially with older patients who may not speak English very well or at all. The majority of IHS settings have an interpreter on staff, or other bilingual staff members who can help with translation. However, caution must be used in this circumstance, because when it comes to health care terms there is little room for misinterpretation.
“Some medical terms, such as cancer, don’t translate into the Navajo language, for example,” Stephens explains. “The term for cancer in Navajo could be described as ‘lood doo na dziiyigii,’ which means ‘a sore that does not heal.’
“Traditional Navajos believe that spoken words are like arrows, and arrows can wound people,” she adds. “Therefore, it would not be appropriate to discuss the patient’s mortality or potential outcomes in the first person. In order to avoid ‘inflicting wounds,’ the care provider must discuss the medical condition in the third person–for example, ‘some people experience x, y and z.’”
The Setting
One of the most distinguishing features of a nursing career with the IHS is where you work. The vast majority of IHS hospitals and clinics are set on or near Indian reservations, which are usually in rural areas. Not only are they small communities, but they’re often located at substantial distances from the nearest town or city, which can be problematic for nurses who have families or are not accustomed to small-town life. For example, there may not be immediate access to employment and social outlets for spouses and children.
“Families have to adopt a certain lifestyle to live in our communities,” notes Stephens. “We need nurses who have a sense of adventure, are willing to accept the challenges of a rural lifestyle and are interested in being involved in the communities they serve. On the other hand, IHS nurses get to experience the [richness of] Native community life and culture. You may not get that opportunity in the private sector.”
Indeed, when HHS Secretary Tommy G. Thompson announced the awarding of $1.7 million in grants to six American Indian and Alaska Native tribes and organizations last fall to assist them in recruiting and retaining health care professionals, he specifically cited location as a contributing factor to the ongoing need for health care personnel. “The national shortages of nurses, physicians, pharmacists and many other health professionals is particularly serious in the remote and isolated areas where many tribal communities are located,” Thompson noted.
The HHS grant recipients were the Maniilaq Association in Alaska ($99,931), the Ketchikan Indian Corporation in Alaska (($91,693), the Seneca Nation of New York ($96,467), the Nisqually Indian Tribe in Washington state ($100,000), the Confederated Tribes and Bands of the Yakima Nation in Washington ($100,000) and the Northwest Portland Area Indian Health Board in Oregon ($92,209).
The Opportunities
Like other health care employers that urgently need more nurses, the IHS is intensifying its recruitment and retention efforts, both within and outside the American Indian and Alaska Native communities it serves.
“Having Native American nurses in the community is probably our biggest retention key,” says Parker. “Many of them have been able to go to nursing school through IHS scholarships and they come back here [to work] and they stay. They are our staple staff.”
For More InformationFor general information about career opportunities in the Indian Health Service:
www.ihs.gov To view current IHS job listings:
www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/Index.cfmFor information about the U.S. Public Health Service Commissioned Corps:
www.usphs.govFor information about the IHS Loan Repayment Program:
(301) 443-3396
www.ihs.gov/JobsCareerDevelop/DHPS/LRP/lrpsc.asp
Of course, another key to attracting and retaining nursing talent is to offer plenty of professional development opportunities. And the IHS certainly has its share. For example, new RN graduates can compete for a position in the RN Internship Program, which allows them to rotate through a variety of different nursing specialties in a preceptor-like training environment.
Another option is the Public Health Nurse Internship, where nurses with BSN degrees receive specialized training as health educators and advocators. For nurses with at least one year of clinical experience, the IHS offers residency programs in critical care, OR and obstetrics, often with the opportunity to become certified upon completion.
To participate in any of these programs, however, nurses must be willing to move around, because they are only offered at specific IHS facilities. “We have the most difficulty recruiting in obstetrics or the OR because there are so few IHS hospitals in our area that offer those training programs,” states Parker. “We’re trying to develop more programs locally, but for now, we also work with outside hospitals that might provide our nurses with training services.”
Then there are long-term training and continuing education opportunities that help nurses at various career levels pursue academic degrees. For example, American Indian and Alaska Native nurses employed with IHS, tribal or urban facilities can take advantage of long-term training opportunities such as the Section 118 program. In this program, which is sponsored by the IHS Headquarters Division of Nursing, LPNs can pursue either an associate’s or bachelor’s degree in nursing; RNs with associate’s degrees can pursue BSN degrees.
“To date, more than 55 nurses have received advanced training and additional degrees through IHS long-term training programs,” says Stephens. “Currently we have 18 nurses in advanced training. Nurses receive full salary, benefits, books and tuition while pursuing advanced education. That’s a benefit the private sector usually does not offer.”
In addition, financial aid opportunities for third- and fourth-year student nurses are available through COSTEP, the U.S. Public Health Service’s Commissioned Officer Student Training and Extern Program.
But perhaps the single most irresistible benefit for nurses is the IHS Loan Repayment Program. Simply put, this program offers nurses–including tribal direct hires–repayment of up to $20,000 per year toward nursing education loans. In return, the nurses agree to a minimum two-year service contract at an IHS facility, usually one that has a high nursing vacancy rate.
The Experience
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Being an Indian Health Service nurse is an opportunity for minority nurses of all races and ethnicities to live a unique personal and professional experience that is simply not available anywhere else. Not only will you encounter a fascinating culture and people, but your expertise as a nurse will be valued and broadened. Within a health care system that offers such a broad spectrum of services, the opportunities to explore different career specialties and gain additional skills are wide open.
“When I worked in the private sector, I didn’t have the ability to move from clinics to ambulatory to inpatient or emergency,” says Parker. “But within the IHS, you can work in a variety of areas and with a variety of cultures.”
You’ll also see how your efforts to care for, educate and advocate for patients can have a ripple effect on the entire community. As Sockabasin explains, “When you work for the IHS, you have the ability to touch a population that is in so much need of good nurses.”
A decade ago, a smattering of nursing schools first began offering degree and certificate programs that focus specifically on minority health, eliminating health disparities and serving the needs of vulnerable patient populations. More recently, however, both the number and quality of these programs has begun to increase significantly.
“In the last five years, there has been a more serious attempt at understanding what we should be doing in these types of programs,” says Shirley Moore, PhD, RN, FAAN, director of a new pre- and post-doctoral training program at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland that prepares nurses for research careers focused on vulnerable populations with multiple morbidities. “These programs are moving to more substantive issues in minority health and a greater understanding of culture as a context for care.”
A primary reason for this shift is the increased national awareness of the crisis of minority health disparities. Studies such as Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the landmark report issued by the Institute of Medicine (IOM) in 2003, have documented extensively that Americans of color do not receive the same quality of care as the white majority. The IOM report also suggested that bias, prejudice and stereotyping on the part of health care providers may contribute to these differences in care.
The underlying principle of social responsibility runs deep in the nursing profession. As nurses become increasingly concerned about health care inequities in communities of color, they are spurred to gain a better understanding of these issues and to build the skills needed to address them. “Nurses have always had the underlying value of tailoring care and incorporating patient preferences,” says Moore. “But how do we tailor care for patients when we don’t know much about their [cultural] background?”
Another reason for the proliferation of these programs is that federal agencies, such as the Health Resources and Services Administration (HRSA), have earmarked millions of dollars in funding specifically for nursing schools. In fiscal year 2006, the agency awarded 151 Advanced Education Nursing grants, 53 Nursing Workforce Diversity grants and 138 Nurse Education Practice and Retention grants, says Annette Debisette, PhD, ANP, RN, director of HRSA’s Division of Nursing. Last year, HRSA appropriated almost $150 million to nursing schools that offer programs focusing on underserved populations.
“The availability of [federal] dollars has permitted us to act on our good will to create these centers and programs that train people with new views on how to approach [cultural issues in nursing care],” Moore says.
Changing the Student Profile
Many of these minority-health-focused nursing programs are attracting a highly diverse mix of students from a wide spectrum of racial and ethnic backgrounds. While they are not targeted specifically to students of color, there’s no denying that these types of programs have helped boost minority enrollments in nursing schools across the board.
“Every training program we’ve had that was working toward understanding diversity, access to care and other minority health issues has been a big attraction for minority students,” says Moore. She adds that the new pre- and post-doctoral training program “is changing the profile of the doctoral student here at Case.”
The Catholic University of America (CUA) School of Nursing in Washington, D.C., offers three HRSA-funded master’s degree tracks in community/public health that focus on decreasing health disparities and increasing the number of nurses from minority populations. Of this year’s graduates, 58% are students of color, says Eileen Sarsfield, PhD(c), MSN, APRN, BC, project manager of the Immigrant, Refugee and Global Health Clinical Nurses Specialist (CNS) Program track.
Three quarters of the students enrolled in this track for the fall semester are racial and ethnic minorities. “This program appeals to nurses who are immigrants themselves or minorities interested in giving back to their community,” Sarsfield notes.
Most of these types of programs are offered at the graduate level, and the nurses who are enrolling in them are as diversified in their career tracks as they are in their ethnic and cultural backgrounds.
Of the 33 students currently enrolled in the University of Texas at Arlington School of Nursing’s PhD program, which focuses on preparing nurse scientists to meet the health needs of diverse and vulnerable populations, some are nurses who work in an administrative capacity at large health care organizations, says Jennifer Gray, PhD, RN, associate dean of the program. Others are nurses with years of clinical experience at the bedside or advanced practice nurses who want to move into a leadership or management role. Some are faculty members at other educational institutions. Some of the full-time students work as graduate research assistants.
Similarly, the 60 students enrolled in the University of Illinois at Chicago (UIC) College of Nursing’s Adult/Geriatric Nurse Practitioner programs, which focus on caring for diverse patient populations, range from master’s-entry students making a career change into nursing to RNs with a few years of experience, says Jean Berry, PhD, RN, CNP, director of the nearly three-year-old programs.
There are even some students coming directly from the undergraduate nursing program, Berry reports. However, they are encouraged to work part time to gain clinical experience, because that will help when they start their clinical courses.
Common Goals, Different Options
While these types of programs all share a common focus on improving the health of underserved populations, each one has its own unique twist. Some are research-oriented, others have a clinical focus and still others address the need for more nursing educators who are specialists in minority health issues.
The goal of Case Western Reserve’s program is to prepare a cadre of nurse researchers committed to the elimination of health disparities. The nursing school received a grant from the National Institute of Nursing Research (NINR) to create the program, which was launched in Fall 2006.
“We’re looking for nurses who understand that [these] patients come with multiple morbidities,” says Moore. “They have diabetes, hypertension, cardiovascular disease and arthritis. Studying only one of these conditions in isolation doesn’t provide a good picture of how to manage the patient’s health.”
Students learn new study design methods and statistics based on complexity science that take into account that it’s difficult to disentangle the factors associated with health disparities in vulnerable populations, she adds.
Moore is hoping to collaborate more closely with other academic departments, such as sociology and anthropology, as well as the Case School of Medicine’s Center for Reducing Health Disparities and Center for Health Promotion. “Working with the different disciplines and centers will help our students get a bigger picture,” she explains.
The new pre-/post-doctoral training program’s minority health focus is also helping the school’s entire nursing faculty expand its parameters. “It has galvanized us around understanding the complexity of health care issues [affecting] people who are economically disadvantaged, and what that means in terms of the impact on the mental, physical and psychosocial health of this population,” says Moore. “The program is challenging us about the methods we’re using, the knowledge we’re producing and how we’re moving into social policy and practice.”
The University of Texas at Arlington’s PhD program offers two areas of study: clinical research and academic role development. The clinical research track is designed to prepare nurse scientists for original research and theory development that will improve health care for diverse and/or vulnerable populations. The academic role development track focuses on developing nursing faculty who will create learning environments that attract students from culturally diverse backgrounds and prepare them to provide care to diverse populations.
Students in the Catholic University of America’s community/public health MSN program who are interested in working with underserved populations can choose from three different options. In addition to the Immigrant, Refugee and Global Health Clinical Nurse Specialist track, there is also a Promoting Healthy Families in Vulnerable Communities track and a Community/Public Health Nurse Specialist Educator track.
The Promoting Healthy Families program prepares students for the blended role of family nurse practitioner and community/public health CNS. The Nurse Specialist Educator program is designed to prepare community/public health nurses to teach in associate and baccalaureate degree programs, staff development programs and patient/family education programs. This track addresses the critical shortage of nursing faculty and strives to improve community-based care for vulnerable populations.
Serving the Global Community
Last July, CUA’s School of Nursing was awarded a three-year, $778,077 HRSA grant to create the Immigrant, Refugee and Global Health CNS program, the newest of the three tracks. As the name implies, the program’s goal is to prepare community and public health nurses to improve access to health care and reduce health disparities in medically underserved immigrant and refugee populations. The program also seeks to attract immigrant and international students as a means of diversifying the nursing workforce and giving immigrant and refugee patients access to caregivers who share a similar cultural and linguistic background.
Students gain exposure to theoretical content and clinical experiences that focus on health policy, global health issues, finance and information systems, and emergency preparedness.
“Nurses involved in immigrant and public health need to know about policy structures, such as Medicare, Medicaid and the State Children’s Health Insurance Program,” says Sister Rosemary Donley, PhD, APRN, BC, ANP, FAAN, project director for both the Immigrant, Refugee and Global Health CNS program and the Community/Public Health Nurse Specialist Educator program. “They also need to know about immigration issues and about diseases that are endemic to different parts of the world, such as tuberculosis and malaria.”
Despite their differences in focus, the three tracks have one thing in common: Most of the students in the programs have a strong sense of social responsibility and many are mission focused. “We don’t get a call from someone asking, ‘How much money will I get when I graduate?’” says Sarsfield. “That’s not usually the kind of students we attract.”
Adds Donley, “They come here because they want to work with underserved populations with health disparities. When they graduate, most do just that.” In fact, 62% of the programs’ graduates work in underserved areas. Many work for public health departments and community clinics, and some have long-term goals of opening clinics in developing countries. CUA has agreements with several entities, such as the U.S. Congress and the World Bank, to provide students with health policy practicum opportunities.
Increasing Students’ Access
Social responsibility is also at the core of the Fuld Fellowship program at Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta. The program, made possible through a grant from the Helene Fuld Health Trust, targets career-changing students with degrees in fields other than nursing who are strongly committed to improving care for vulnerable populations.
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The full-tuition fellowship provides much-needed assistance for these students, who typically don’t have as much access to financial aid resources as first-degree nursing students, says Ann Connor, MSN, RN-C, FNP, assistant professor of nursing. Since 2001, eight students have graduated from the program, and there are 14 Fuld Fellows currently enrolled.
Fuld Fellows attend core courses leading to a BSN degree, followed by a master’s degree in specializations such as nurse-midwifery, public health and family nurse practitioner. They also participate in the school’s social responsibility programs, such as the Farm Worker Family Health Program (http://www.whsc.emory.edu/_pubs/en/2003spring/feature_lessons.html), Alternative Spring Break Trips (http://www.whsc.emory.edu/_pubs/en/2005winter/newsbriefs.html) to work with HIV/AIDS patients in Jamaica and the Bahamas, and the Korean Exchange Program (http://whsc.emory.edu/_pubs/en/2003spring/feature_root.html).
These second-degree nursing students enrich the pool of nurses because of their diverse professional and educational backgrounds, says Connor. They have the advantage of maturity and a variety of life experiences and skills that allow them to assess issues from a different perspective than traditional nursing students. “They help change health care delivery models because they come with fresh ideas,” she explains.
Some nursing schools are using distance learning to make their minority-health-focused programs more accessible to students. The Oregon Health & Science University (OHSU) School of Nursing in Portland has an online Master of Public Health (MPH) degree program focusing on primary health care and health disparities. It is offered in conjunction with the Oregon Master of Public Health (OMPH) program (http://www.oregonmph.org/), a collaborative statewide degree program offered through OHSU, Oregon State University and Portland State University.
Launched in 2005, the Primary Health Care & Health Disparities MPH program emphasizes improvement in primary health care accessibility and quality for underserved populations. The curriculum evolved over a year of increasing collaboration between the MPH program and OHSU’s Center for Health Disparities Research, explains associate professor of nursing Deborah Messecar, PhD, RN, MPH, CNS.
The program currently has approximately 40 students, roughly half of whom are nurses. The Center for Health Disparities Research has relationships with community-based agencies, creating opportunities for student field experiences. The program is also linked to the international initiatives of the OHSU School of Nursing’s External Programs, giving students opportunities to work with vulnerable populations in Thailand and Ecuador.
Students with a Mission
Why are students responding so enthusiastically to these new nursing programs that focus on minority health and cultural diversity issues? It’s because many of the students pursuing these degrees have a deep commitment to serving vulnerable populations and eliminating health disparities—a commitment that has been fueled by work-related experience, personal experience or both.
Carmen Alvarez, who graduated in May from the Fuld Fellowship program at Emory University’s Nell Hodgson Woodruff School of Nursing, believes that nurses are obligated to help the underserved and that they become empowered when they learn how to address the issues that affect these patients. “When we don’t address their health care issues as early as possible, [those problems] are going to become more challenging, and then we’re going to see the effects in the hospital or at the tertiary level, which is more costly and taxing for us as health care providers,” she says.
For Alvarez, who is of Belizean descent, the motivating factor that led her to return to school and pursue a nursing degree after four years of conducting research in nutritional science was her exposure to marginalized groups in the developing countries in which she lived up until the age of 13. Her father was a plant geneticist who traveled to countries such as Nigeria and Rwanda to help farmers improve their crops.
Tarsha Jones, a full-time student in the Catholic University of America’s community/public health MSN program, points out that the growth of immigrant and refugee population in America means that even more people from disenfranchised groups will require health care in the future. “We need to reach out to them to provide knowledge and resources to improve their health outcomes,” she emphasizes. “If we can focus more on health promotion and disease prevention within specific minority populations, eventually we will improve the overall health of our country.”
Jones, a former pediatric nurse, was born in Jamaica and emigrated to the U.S. when she was 10 years old, so she knows firsthand what it’s like to be a part of a disenfranchised group. “I have a working understanding of being an immigrant and of not having one’s health care needs represented,” she says.
At least once every two years Jones returns to Jamaica, where some impoverished areas don’t even have running water. “Being in a Third World country has opened my eyes to realize what a great opportunity I have living in America and being able to attend a graduate school like CUA where they encourage us to be aware of what’s going on nationally and also internationally,” she says. “[This program] is empowering us to help people here in the United States and also giving us a better understanding of global health nursing.”
When she graduates in 2008, Jones plans to obtain a leadership position in program development where she can work on health promotion and disease prevention to benefit vulnerable minority populations.
Similarly, Alvarez would eventually like to work for an entity such as the World Health Organization (WHO) that uses clinical research to affect public policy. It may take her a little longer to get there, though. This summer, she began pursuing her PhD in nursing with a focus on health promotion and risk reduction at the University of Michigan in Ann Arbor.
Karen Johnson-Guy returned to school after five years of working as a nurse in high-risk obstetrics. With a master’s in nursing and certification as a nurse-midwife and childbirth educator, she plans to start pursuing a PhD in nursing with a focus on vulnerable populations from Case Western Reserve University’s Frances Payne Bolton School of Nursing this fall. After conducting research in Uganda on midwives’ attitudes toward patients with HIV, she knew that she wanted to prepare herself for a career as a nurse scientist. Her research interests include breastfeeding and preventable pathologies of newborns related to the intrauterine environment in mothers who are addicted to crack cocaine and/or methamphetamines.
Johnson-Guy feels that her personal experience of having grown up in public housing projects in inner-city Minneapolis enables her to relate to medically underserved people with health disparities. And where does she see herself five years from now? “I see myself with a PhD—teaching, practicing and researching.”
Some two million American Indians and Alaskan Natives in the United States are eligible to receive health care through tribal health programs. As a result, there are a great many opportunities for nurses to provide care for Indian patients living in tribal communities, in a wide variety of settings-from tribal clinics, Indian Health Service (IHS) facilities and tribally run health care institutions to reservations, tribal trust lands and urban clinics.
According to the most recent National Sample Survey of Registered Nurses, there are only about 13,000 American Indian/Alaskan Native (AI/ AN) nurses in the United States-not nearly enough to provide health care for the entire Indian population. As a result, tribal communities must depend on the collaborative efforts of both Indian and non-Indian nurses if they are to receive adequate, accessible and culturally competent nursing care.
But no matter what their race or ethnicity, all nurses who work with Indian populations in tribal settings must understand and appreciate the political and health history of AI/AN tribes if they are to truly provide effective, culturally sensitive care. Many nurses who work with tribal communities-even if they are Native Americans themselves-may not fully understand why Indians have different health resources than the general population, because they lack awareness of the political and historical issues involved and how these issues directly impact health care delivery.
There are over 550 federally recognized Indian tribes in the U.S. and each tribal government is set up differently. Many of these tribes are now managing their own health care programs; some tribes even have their own health insurance. Tribal governments frequently include health boards that make policy decisions affecting health care in general and nursing in particular.
Trust responsibility, tribal sovereignty, tribal politics and self-governance are all terms that are commonly used in Indian communities, including their health care programs. Both Indian and non-Indian nurses who want to work successfully in tribal settings need to understand what these concepts mean and how they affect their roles as nurses.
Trust Responsibility
To understand why Native Americans have tribal health programs that are set apart from the rest of the U.S. health care system, nurses must understand that there is a trust responsibility, established by treaties, between the federal government and Indian tribes. In the 1830s, Chief Justice John Marshall coined the term “domestic dependent nations” to describe the fact that tribes are under the protection of the United States.
This promise by the federal government to provide for the tribes led to the creation of the Indian Health Service, an agency of the U.S. Department of Health and Human Services that is responsible for providing federal health programs to American Indians and Alaskan Natives. It is important for nurses to understand that by working in Indian health care programs, they are helping to fulfill the government’s trust responsibility toward the Indian nations under its care.
Tribal Sovereignty
Tribal sovereignty means that Indian tribes have the status of independent nations, recognized as such by the federal government, with the inherent right to govern themselves. Today, 500 years after their first contact with Europeans, tribal nations remain distinct political entities. Although they function within the states in which they are located, each tribe operates internally as a sovereign government that deals with the federal system on a government-to-government basis.
The independence and power inherent in tribal sovereignty was strengthened during former President Clinton’s administration, when he decreed that tribal nations and the federal government must consult jointly on issues that directly affect tribes.Tribal sovereignty is an important part of Indian health care, because it is through these government-to-government relationships that tribal nations negotiate for federal health care funding. As the concept of tribal sovereignty has become better understood by the federal government, tribes have increasingly demanded and gained more control over the right to manage their own health care issues and programs-e.g., by taking over the management of former Indian Health Service facilities (see “Self-Governance”). In turn, the IHS has begun downsizing its structure and encouraging more Indian nations who receive federal funding to manage their tribal health programs directly.
Tribal Politics
Many tribes, such as the Chippewa Cree of Montana, have committees or boards that directly oversee health care issues and the dispersement of health care funds. An important role of nurses who work in tribal settings is to advise and educate tribal politicians about health issues that will affect the board’s decision-making on tribal health policies. In fact, nurses are often the politicians’ sole source of health-related information.
A notable example of this is the recent Supreme Court decision in which the Mille Lacs Band of the Ojibwa tribe regained their tribal rights for hunting and fishing on Indian lands. The influence of public health nurses who were working with the tribe to promote awareness of healthy lifestyles helped tribal leaders identify this as a health-related issue: By being able to hunt and fish, the Ojibwa people were able to return to a more traditional diet, which would help reduce the risk of diabetes in their community.
Self-Governance
Self-governance, a tribal rights movement that emerged in the 1980s, refers to a tribe’s decision to manage its functions and programs itself, as opposed to having them managed by a federal agency or administrator, such as the Bureau of Indian Affairs. A group of 10 tribes, including the Cherokee Nation, took the lead in establishing themselves as self-governance tribes that would receive funding from the federal government but decide for themselves how to spend that money. Today, more than half of the nation’s tribes identify themselves as self-governance tribes.
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The goals of the self-governance movement are to promote self-sufficiency, establish accountability, reduce bureaucratic red tape and change the roles of federal agencies as they relate to tribes. In the specific context of health care, self-governance means a tribe has exercised its right to run its own tribal health programs, rather than receive health services provided through the IHS.
Native and non-native nurses alike are needed to work in both tribally run and federally run Indian health programs. Tribes view nurses-and Indian nurses in particular-as knowledgeable health care professionals who can play a vital role in helping to direct and supervise tribal health care programs. Therefore, nurses who plan to work in tribal settings must understand that they may be expected to provide not only clinical patient care but also the management expertise needed to actually run clinics or other facilities.
Above all, nurses must understand that tribes know best when it comes to their own health care needs and how to allocate their resources and energies in the right direction. Armed with this insight and wisdom, nurses have the power to make unlimited contributions to improving the health of American Indians and Alaskan Natives.
