A Nursing School on Reservation Land : AJN The American Journal of Nursing

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A Nursing School on Reservation Land

Wilson, Deborah MPH, MSN, RN; Werk, Alicia BSN, RN; Hemmer, Brigit MSN, RN

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AJN, American Journal of Nursing: December 2022 - Volume 122 - Issue 12 - p 49-55
doi: 10.1097/01.NAJ.0000904096.09348.6a
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Figure:
The founders of the Grow Our Own nursing program were honored during a traditional blanket ceremony on February 24. Recipients, left to right, are Cynthia Gustafson, then director of the Montana State Board of Nursing; Carole Falcon-Chandler, past president of Aaniiih Nakoda College; tribal elder Minerva Allen; and Brigit Hemmer, director of the program. Photo by Bob Parsley.

Education is the return of the buffalo.

—Aaniiih proverb

The Aaniiih and Nakoda people of the Fort Belknap Indian Reservation experience some of the worst health outcomes in Montana.1, 2 Blaine County, which includes Fort Belknap, has been ranked in the lowest quartile in the state for clinical care (access to care, quality of care), social and environmental factors (education, employment and income, community safety), and physical environment (air and water quality, housing, and transit).1

In 2016, the associate of science in nursing degree program Grow Our Own (known as in the Aaniiih language and in the Nakoda language) was established at Aaniiih Nakoda College on the Fort Belknap reservation. The primary aim of the program is to ensure nurse graduates are knowledgeable and skilled and can provide culturally safe care, potentially improving the health and well-being of Native Americans and others living both on and off the reservation.3 The program exemplifies how increasing diversity in the profession can be achieved despite barriers often cited as deterrents to underrepresented students' success.

This article provides a closer look at how and why the Grow Our Own program came to be established, successful strategies and lessons learned, and how a collaboration with another nursing school aims to ensure graduates return to the Fort Belknap reservation to assume administrative and faculty positions at the tribal college.

HEALTH DISPARITIES AND CHALLENGES

Native Americans have some of the worst health outcomes compared with other racial and ethnic groups.4 A lack of resources and opportunities for both urban and reservation-based Native Americans has put this population at risk for physical and mental health impacts.1, 5 The life expectancy of American Indians and Alaska Natives born today is 5.5 times lower than that of the overall U.S. population, with the burden of diseases such as diabetes and tuberculosis disproportionately higher among American Indians, resulting in the need for more frequent medical care.4, 6 Difficulty accessing medical care in reservation communities, the racism that affects interpersonal encounters between patients and health care providers, and structural racism that increases barriers to health care access can result in missed appointments and greater health disparities.7 Furthermore, reservation-based Native Americans often live in communities that struggle with high crime rates, poor housing conditions, and poverty.8 Racism and the intergenerational traumatic effects of colonization (genocide, forced relocation, and assimilation into the dominant culture) can contribute to health disparities, raising the risk of abuse, posttraumatic stress disorder (PTSD), and youth suicide and substance use.8

ACCESS TO CARE AT FORT BELKNAP

The Fort Belknap Indian Reservation is in north-central rural Montana and spans 675,147 acres. It's located 40 miles south of the Canadian border.2 The average annual unemployment rate on the Fort Belknap reservation in 2017 was 33.9%, much higher than the 13.1% rate for residents of all reservations in the state.9 The median household income of those living at Fort Belknap is $44,772 compared with $56,539 in Montana overall. Forty percent of people on the reservation live below federal poverty levels compared with 12.8% statewide.10 The suicide rate among American Indian youth in Montana who are 11 to 24 years old is 42.82 per 100,000 compared with a statewide rate of eight per 100,000—more than five times higher.11 Fort Belknap, like other Montana reservations, has struggled with suicide clusters and crises in recent years.12

The reservation's remote location complicates access to medical services. The Indian Health Service's Fort Belknap Service Unit provides only short-term acute care (a critical access hospital, ambulatory care, and 24-hour urgent care).13 Specialized medical care requires referral to regional hospitals in Great Falls, which is 160 miles from the reservation, or Billings, which is 200 miles away. There are no inpatient psychiatric care services on the reservation. The Fort Belknap Tribal Health Department's 11 nurses fill some of the gaps in access to care, providing education and nursing care, including follow-up care, to people in their homes.

EDUCATION GROUNDED IN INDIGENOUS LIFEWAYS

Chartered in 1983, Aaniiih Nakoda College provides postsecondary education to residents of the Fort Belknap reservation and surrounding communities.14 Eighty-four percent of students are Native American, 91% of whom are enrolled members of the Aaniinen and Nakoda nations.14 Ninety-one percent are first-generation college students, and more than 90% qualify for federal financial aid.14 The college is grounded in the Indigenous lifeways of the Aaniinen and Nakoda tribes and promotes individual and community development.15 It's one of 37 tribal colleges and universities that aim to overcome the barriers to higher education that reservation-based Native Americans face, providing opportunities and “programs that are locally and culturally based, holistic, and supportive,” according to the American Indian Higher Education Consortium.16

Native American communities draw tremendous strength, resilience, and well-being from being rooted in cultural lifeways, connection to the land, kinship, and community.17 Incorporating native language and cultural lifeways into school programs has supported student success from early childhood education to college.18, 19 Native American students in higher education can gain greater understanding, success, and confidence when Indigenous epistemologies and pedagogies are included in curricula and coursework.19 Historically, Native American students are the most underrepresented population in higher education and have the highest dropout rate of any group in the United States. There is a gap in research evaluating strategies to improve Indigenous student success and resilience.20

Approximately 6.5% of the Montana population is American Indian, but only 2.3% of RNs in Montana are American Indian.14 Recent data show that the number of newly registered Native American nurses has declined slightly in recent years, highlighting the need to increase diversity in nursing, particularly by recruiting Native Americans into the profession.21, 22 Furthermore, a report investigating poor health outcomes in urban Native Americans in Montana found that the health disparities and lack of access to health care could in part be attributed to interpersonal, institutional, and structural racism.23 To address these issues, the report recommends increasing the diversity of the health care workforce, improving the cultural competency of staff, and expanding understanding of Native American traditional practices and integrating these into Western medicine.23 Having clinicians who understand the challenges Native Americans face may encourage greater utilization of health care services and improve the quality of available care.23

ESTABLISHING A NURSING SCHOOL

After a particularly bad experience as a patient, Carole Falcon-Chandler, who was then the president of Aaniiih Nakoda College, decided to find a way to have her own people care for her, should she require another hospitalization. The vision for the Grow Our Own nursing program was born from this desire and grew after she heard about repeated incidents in which respected tribal members were mistreated when hospitalized. A conversation in the college parking lot between Falcon-Chandler and the former head of Aaniiih Nakoda College's allied health program, Elizabeth McClain, highlighted the strength of this department, the need for more Native American nurses, and the wish to be able to provide training for reservation-based nursing students who struggled with the long distances they had to travel to receive the required training. In that parking lot, the decision was made to find out what it would take to start a nursing program at Aaniiih Nakoda College.

A proposed nursing program must navigate three phases to receive approval from the Montana Board of Nursing.24 Falcon-Chandler, who was president of Aaniiih Nakoda College from 2001 to 2020, convened a community forum on campus in December 2014 to establish interest in the program. The then executive director of the Montana Board of Nursing was present to help answer questions, and elders, tribal council members, the college president, faculty and staff, students (particularly from the prenursing allied health program), and members of the community attended. Articles about the potential nursing program were subsequently published in newspapers in the surrounding community, and the Fort Belknap radio station hosted a talk show discussing the steps required to establish such a nursing program. Feedback from this outreach and the community forum revealed overwhelming support for the establishment of a nursing program at Aaniiih Nakoda College.

Phase one: notice of intent. A requirement of this phase, which was formally initiated in March 2015, is a needs assessment, in which potential and available students and employment opportunities for program graduates are identified.24 Before the notice of intent was formally submitted, an online needs assessment survey was uploaded to the Aaniiih Nakoda College website in December 2014. Within a month, nearly 150 responses were recorded, with 76% of respondents strongly in favor of a nursing school, 89% voting for a focus on cultural strengths and safety, and 94% saying the school would have a positive impact on the health of the community.14 Community members requested that the nursing program include support for the Aaniiih and Nakoda languages, provide for clinical placements in the local and surrounding communities, and include innovative educational methods, such as a simulation lab.14

With strong community support, formal meetings with the tribal council, which consists of equal representation of Aaniiih and Nakoda members, were scheduled. A tribal resolution is the formal legislative step a tribal government takes to support and guide an initiative.25 Two tribal resolutions were obtained: one approving the establishment of a nursing education program and another approving Aaniiih Nakoda College's request to seek funding. This allowed the college to submit a proposal for a five-year Administration for Native Americans' Sustainable Employment and Economic Development Strategies grant for the development and support of the nursing education program. As part of the phase one requirements, the governing institution has to commit to having sufficient financial and other resources to plan, implement, and continue the program.24

After reviewing the tribal council approvals, documented proof that Aaniiih Nakoda College is fully accredited through the Northwest Commission on Colleges and Universities, and numerous letters of support from organizations, leaders, and medical facilities, the Montana Board of Nursing issued official approval to begin the next phases of the process.

Phase two: application for initial approval for admission of students. The Montana State Board of Nursing approved this phase of the project in April 2016. Aaniiih Nakoda College developed the structure of the nursing program and needed to provide evidence of hiring faculty and a nursing director and an overview of the curriculum.24 During curriculum design, emphasis was placed on a holistic approach to health, in keeping with Indigenous world views on health and well-being rather than the Western, individualistic model of reducing risk or illness.26

Memorandums of understanding were drawn up between Aaniiih Nakoda College, clinics, hospitals, and other facilities in Fort Belknap and the surrounding communities to establish sites for professional clinical experience for nursing students.3 A detailed initial program evaluation plan was drawn up using the American Association of Critical-Care Nurses' guidelines to assess level of performance and practice. A nursing student handbook was also developed.3

Finally, an on-site inspection visit was conducted by the Montana Board of Nursing, after which approval was granted to begin accepting students. The first five students started in the Grow Our Own nursing program at Aaniiih Nakoda College in 2016. An additional three cohorts, comprising 35 students in total, subsequently completed the program, with a fourth cohort, made up of 13 students, graduating this past spring. All students were eligible to sit for the National Council Licensure Examination. A new cohort of nine students started in the program this fall.

Phase three: full approval of the program. Full approval is contingent on submission of a self-study report and completion of a site survey by the Montana Board of Nursing after graduation of the first class of students. This is to verify that the program complies with the board's nursing education standings.24 During a January 2020 board meeting, the Grow Our Own nursing program earned full approval.

As part of phase three, the collection of data to monitor the progress of the program continues. To date, 84% of graduates are employed in medical facilities on the reservation or in surrounding communities, according to the director of the Grow Our Own nursing program (one of us, BH). Three graduates are enrolled in an RN-to-BSN program, and others are planning to apply.

SUCCESSFUL STRATEGIES AND LESSONS LEARNED

Working in a community struggling with many negative social determinants of health and stressors means that students are often dealing with personal and family issues, and the Grow Our Own faculty have had to accommodate this. These issues include caring for young children; family members struggling with serious or chronic illnesses; deaths in the family and community; and students experiencing limited support systems, a lack of financial resources, or complicated relationships while attending a full schedule of nursing classes and clinical rotations.

Financial assistance. As is the case for many students from underrepresented populations, tuition costs for Native American students can be prohibitive. Anticipating this, the tribal college's grant through the Administration for Native Americans was used to provide students with scholarships and stipends that allowed them to enroll in the nursing program. All tribal colleges are dependent on grant funding, and the sustainability of the nursing program has been made possible by a grants specialist who works to locate and assist in ongoing applications for funding the nursing school. During the COVID-19 pandemic, it was also necessary to overcome internet service access barriers, so the college provided laptops, access to hot spots, or internet service to students, allowing them to attend synchronous and asynchronous virtual classes. This enabled students to complete their coursework, including virtual simulations to meet required clinical hours.

Extra didactic education support has helped ensure student success. Students from less resourced communities are often at a disadvantage educationally; they may have access to poor performing schools and less exposure to the sciences prior to college.27 Extra math remediation, for example, has been important for learning safe dosage calculation.

Frequent student advising has also become an essential strategy. Meeting with each student every two to three weeks allows faculty to help the students stay on track and ensures students receive sufficient support for practical or personal needs. This has included accommodating assignment extensions, approving leave for family and community cultural ceremonies, and rearranging clinical schedules due to COVID-19 pandemic restrictions. Although this is labor intensive for faculty, creating a successful nursing school in an Indigenous community requires such attention if students are to successfully graduate.

Mentorship. Evidence suggests that another strategy that can help with the retention and graduation of diverse nursing students is mentorship by faculty and other students.28 The presence of Native American faculty is imperative for Aaniiih Nakoda College students. Native American faculty support Indigenous students through their shared cultural knowledge and experience and can advise non-Indigenous faculty in the many situations that arise during a semester, as students negotiate family, nursing, community, and school issues. Allyship is often best expressed by non-Indigenous faculty by listening; being willing to learn; stepping in to help manage tasks to support Native American faculty when needed; and providing supportive structures for students, such as regular advising and flexibility with deadlines, which allows students to keep moving forward during times of difficulty.7, 29 Non-Indigenous staff need to be willing to view Native American faculty and student stress within the larger context of past personal, community, and cultural trauma that can affect education, recognizing that they may be potentially struggling with depression, anxiety, or PTSD.30

Timelines and staffing ratios. Other successful strategies have involved flexibility with timelines while maintaining the standards required to graduate knowledgeable and skilled nurses who will provide culturally safe care as they look after people across their life spans. There is also a need to consider the student-to-staff ratio and the number of students within a cohort that faculty can realistically manage each year. Most recently, this has meant that the Grow Our Own nursing program's cohort intakes have occurred every other year to ensure students in each cohort receive the attention and care needed for success.

Culturally safe care. The initial goal of the Grow Our Own program was to increase the training and capacity of the Native American nursing workforce in Fort Belknap and surrounding communities. The program is also helping to increase the diversity of the Montana graduate nursing workforce, which will ideally lead to Native American patients having better access to culturally safe care, which aims to minimize the disenfranchisement of marginalized cultures and calls on nurses to reflect on their practice.31 In the Native American context, cultural safety encompasses an examination of the power structures that erode equity and recognizes the social determinants of health that result in health disparities and the effect colonialism still has on the health and well-being of Indigenous people.32, 33 Culturally safe care also highlights Native American sovereignty, self-determination, and the strength of Indigenous knowledge systems to promote collective well-being.34 It's an important concept taught in the Grow Our Own nursing program.

To enhance the understanding and experience of culturally safe care, the concept-based nursing curriculum in the Grow Our Own program has been adapted to incorporate the principles of the Native American Medicine Wheel, used by generations of tribes for health and healing.3 The curriculum focuses on the social determinants of health and deemphasizes race and ethnicity as the basis of health issues. Native elder teachings are included in the curriculum, and students take courses in the Aaniiih and Nakoda languages and American Indian studies.

Clinical experience in specialty areas. The Grow Our Own program utilizes facilities throughout Montana, with students traveling great distances to gain clinical experience in specialty areas, such as obstetrics and pediatrics. Experience working in the Indian Health Service's ED on the reservation provides significant critical care experience, as it's the only nearby medical care facility. Simulation activities provide students with additional experience.

Degree program decision. When developing this program's curriculum, there was careful discussion about whether to implement an LPN or associate degree program. Aware of the push for baccalaureate-prepared nurses but cognizant of the complex social and environmental issues facing potential students, the decision was made to establish an associate degree program that has pathways to further education incorporated into the curriculum, creating a pipeline to the RN-to-BSN track.

A COLLABORATION BETWEEN NURSING SCHOOLS

One of the goals of the nursing program is to increase the number of faculty members. This requires that Native American nurses aspire to obtain a master's or doctoral degree in nursing. Graduate-prepared nurses from underrepresented populations may be more knowledgeable of the cultural and contextual issues faced by diverse populations and are thus well suited to address the fundamental causes of health disparities.29, 35 Moreover, doctorally prepared nurses can potentially influence health outcomes by conducting culturally appropriate research.35

With a PhD-prepared Aaniiih nurse on the faculty of the Johns Hopkins University School of Nursing in Baltimore, a collaborative effort has been established between the two nursing schools to advance both of their missions: to support diversification in the student and faculty populations at Johns Hopkins and to improve the Fort Belknap community's capacity to address behavioral health needs and improve educational outcomes. Teaching assistant opportunities are available at Aaniiih Nakoda College for Johns Hopkins' postgraduate nursing students. Furthermore, the university is collaborating with the tribal college on research and education initiatives to improve behavioral health outcomes on the reservation; for example, a summer program is designed to educate and empower Native American high school students at Fort Belknap to pursue careers in nursing; public health; and science, technology, engineering, and mathematics.

The experience of working at Aaniiih Nakoda College—initially through a teaching fellowship—has allowed one of us (DW) to contribute to the Johns Hopkins School of Nursing Committee on Teaching and Learning as a Pathway to Diversity, Equity and Inclusion, which is assessing current curricula for embedded biases, incorporating cultural inclusion into its pedagogy, and determining and monitoring impact measures. Another of us (AW) and another Native American student are currently working toward MSN degrees at Johns Hopkins' School of Nursing, utilizing scholarships from the university and mentorship from its Native American faculty—the PhD-prepared Aaniiih nurse and a Navajo psychiatric NP who also has a PhD and was recently hired by the university. They meet monthly, the students receiving guidance and support that helps to ensure they successfully navigate the predominately White educational system and the stressors they experience at home on the reservation.

Several graduates of the Grow Our Own program have returned to the reservation to assist with clinical teaching opportunities. It's hoped that more graduates will eventually take over administrative and faculty positions.

FUTURE DEVELOPMENTS

With many successes and some challenges, the Aaniiih Nakoda College nursing program continues to evolve and grow, bolstered by its grounding in cultural strengths and lifeways. Currently, the college is working toward national accreditation for the program from the Accreditation Commission for Education in Nursing. This will provide the program with formal, national recognition that it meets a set of standards and is trusted to deliver quality education.36

Through the creation of the Grow Our Own nursing program, the vision of Falcon-Chandler has grown from a conversation in a parking lot to a powerful example of how to increase diversity in nursing and potentially improve the health outcomes of Native Americans living on and around a reservation community.

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Keywords:

diversity in nursing; Native American; nursing education; rural health

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