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GOVERNMENT, POLITICS, AND LAW |
Susan J. Henly and Roxanne Struthers are with the School of Nursing, University of Minnesota, Minneapolis. Barbara K. Dahlen and Bette Ide are with the University of North Dakota College of Nursing, Grand Forks. Beverly Patchell is with the Indian Nursing Student Success Program at the University of Oklahoma College of Nursing, Oklahoma City. Barbara Holtz-claw is with the Bridge Project, University of Minnesota, Minneapolis.
Correspondence: Requests for reprints should be sent to Susan J. Henly, School of Nursing, University of Minnesota, 5-160 WDH, 308 Harvard St. SE, Minneapolis, MN, 55455 (e-mail: henly003{at}umn.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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The health status of American Indians/Alaska Natives lags behind that of the US population. American Indian/Alaska Native (AIAN) nurses are on the front lines of health services for AIAN people. They have the potential to make scientific contributions as well, but are under-represented among researchers working to understand health disparities.
The AIAN MS-to-PhD Nursing Science Bridge, at the University of Minnesota, in partnership with the Universities of North Dakota and Oklahoma, provides support for AIAN nurses during the critical training transition from masters of science to doctoral programs. Partner schools collaborate with AIAN elders, medicine people/spiritual leaders, and academic consultants to (1) foster academic success and strengthen the AIAN identity of students during their research training and (2) bring about institutional change to optimize student experiences. Future research programs developed by this cadre of AIAN nurse scientists will contribute scientifically sound, culturally acceptable knowledge to effectively improve the health of AIAN people.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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The United States has committed to the Healthy People 2010 goal of eliminating health disparities among minority and ethnic populations, including American Indians/Alaska Natives in 6 areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, and immunization.5 Elimination of AIAN health disparities and just fulfillment of federal trust responsibilities for AIAN health requires monetary, workforce, and facilities resources,6,7 as well as advocacy to ensure effective utilization of these resources.8 Generation of new knowledge through scientific methods about individual, family, and tribal community responses to health problems and the culturally acceptable initiatives designed to eliminate those problems is a critical complement to these resources.9–11
Nurse researchers are well positioned to discover and develop this needed new knowledge to be used across the range of health services and in the public health arena. Nurses form the largest group of health professionals in nearly all settings, including public health, and are recognized as the "backbone of the IHS [Indian Health Service] health care team" that provides services to approximately 1.5 million AIAN people.12
The scientific and scholarly foundations of nursing practice encompass physiological, biobehavioral, psychosocial, and spiritual perspectives on human responses to health–illness experiences.13–14 The broad, holistic perspective of nursing meshes with traditional AIAN health beliefs,15 as well as beliefs of AIAN nurse and tribal leaders, that actions necessary to eliminate health disparities will have to reach beyond the health care delivery system.9,16
Since 2001, the AIAN MS-to-PhD Nursing Science Bridge, funded by the National Institute of General Medical Sciences (NIGMS), has been educating AIAN nurses whose scientific training is focused on development and dissemination of knowledge and utilization of research findings to eliminate health disparities. This program prepares a scientific workforce poised to perform culturally congruent research in AIAN communities. When the project began, approximately 12 AIAN nurses held doctoral-level degrees. The goal of the Bridge project is to correct this grave underrepresentation of AIAN nurses in science. Through its work, the overall number of nurse scientists is projected to double by 2011. We describe here federal scientific workforce policy as it pertains to the AIAN Nursing Science Bridge. We outline the structure, processes, and outcomes of the project and explain how the Bridge is a pathway to the elimination of health disparities among AIAN people.
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BRIDGES TO THE FUTURE |
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TOPABSTRACTINTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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The AIAN Nursing Science Bridge is unique among bridges to the doctorate because it focuses on research training for AIAN nurse scientists. The project, based at the University of Minnesota School of Nursing, was initiated in partnership with the University of North Dakota College of Nursing (2001–2004) and is continuing with the University of Oklahoma College of Nursing (2003–2007). All 3 schools are located in states where many American Indians reside.
The University of Minnesota was positioned to begin this work by virtue of a longstanding, high-quality PhD program in nursing science, 3 American Indian faculty members, and a research portfolio that emphasizes AIAN health. Both MS partner schools are home to funded programs to support BSN and MS students in nursing.19 The Recruitment and Retention of Native Americans into Nursing (RAIN) programs, based at the University of North Dakota, is one of the Quentin Burdeck Indian Health Programs funded by the Indian Health Care Improvement Act of 1992. University of Oklahoma is home to the Indian Nursing Student Success Program (INSSP), funded as an IHS Section 112 initiative. Sustained success of AIAN students enrolled in BS and MS programs at partner schools reflects the institutional commitment to AIAN nursing education embodied in these projects.
Specific aims of the AIAN Nursing Science Bridge Project are to (1) provide research assistantships to MS students, (2) build research capacity at MS partner schools, (3) ensure culturally informed advisement at the doctoral level, (4) collaborate with AIAN communities in all phases of project implementation, and (5) foster academic success and enhance the AIAN identity of students who, upon earning the PhD in nursing science, are ready to launch research careers focused on elimination of AIAN health disparities. The bridge project structure designed to support achievement of these aims is pictured in Figure 1
. The "bridge" has 2 cultural abutments: academic and cultural. It is suspended by 6 activities that support students, partner schools, and AIAN communities: faculty development, linked recruitment, dual advisement and mentorship, research participation, research dissemination and utilization with guidance of elders and medicine people or spiritual leaders, and a bicultural project retreat. The project supports the MS-to-PhD transition, as students "cross the bridge" from a science-based undergraduate professional degree to a doctorate and a research career.
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JOURNEY TO SCIENCE |
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TOPABSTRACTINTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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Currently, the 8 AIAN nurses participating in the Bridge represent 7 tribes. Six of the 8 students are enrolled tribal members, 2 have AIAN heritage by descent, and all are women. Most students began their post–high school education at community or tribal colleges. As a group, they are older than average students. Many are mothers. Although research methods and research utilization are standard elements of the BSN curriculum in nursing, none had seriously considered a research career until a RAIN, INSSP, or Bridge staff or faculty had suggested it.
Students are motivated to improve themselves and advance their education to serve American Indians/Alaska Natives. Recommendations included with applications to the program describe students as bright, self-directed, and mature. Applicants are characterized as determined, dependable, and diligent, with a commitment to goals they set for themselves. As a group, they are characterized as possessing positive outlooks, bearing compassion, and having a passion for their work. All of these attributes are needed for graduate school success and for a research career developed in collaboration with AIAN communities and health systems.
Fostering Academic Success
Bridge students are assigned advisors from both the MS and PhD school. The system of joint advisement facilitates continuity over the course of both degree programs. PhD faculty advisors and Bridge staff guide students through the application process for the doctoral program, including encouragement for completion of the Graduate Record Examinations requirement.
In addition to the coursework and projects required for the MS degree, Bridge scholars complete a mentored research assistantship with faculty or community-based investigators engaged in AIAN health disparities research. The Bridge program funds the assistantships. Because students earn a salary for work completed, there is no service payback associated with participation. Project funding of the assistantships provides an incentive for faculty participation because it complements their research budgets or provides an assistant when funding is limited or unavailable (for pilot projects, for example).
Most Bridge scholar–mentored research and projects are in priority areas related to the elimination of AIAN health disparities. Projects focus on the scourges of diabetes and its complications, especially renal complications and lower extremity amputation. Projects address health experiences across the lifespan range from prevention of fetal alcohol syndrome to exercise in school-aged children to health experiences and health service needs of elders. Other projects focus on caring for caregivers of people with dementia and attitudes of nursing students toward persons with disabilities.
All students are making timely progress toward degree completion. Three students have transitioned to doctoral study and secured funding. Two students were awarded Graduate School Diversity of Views and Experiences Fellowships in a university-wide competition at the University of Minnesota, and 1 student was awarded a prestigious Hartford Geriatric Nurse Fellowship.20
Enhancing Cultural Identity
Cultural conflict continues to be part of the higher education experience of many AIAN students. The process of completing a doctoral degree conflicts with many AIAN values, such as present-time focus, patience, respect, family, harmony with nature, and circular thinking.21 A huge deterrent for AIAN people enrolling in a university is the loss of AIAN identity.
Despite an emphasis on diversity and a goal of cultural competence for graduates, the content and process of nursing education programs tend to be built on and emphasize mainstream values.22,23 In this climate, retention and progression are challenging. For example, AIAN students enrolled in one MS program reported conflicts between AIAN and academic values and feeling isolated from other students.24,25 Students reported that differences in worldviews, rigid academic environments, barriers to effective faculty–student relationships, and the need to develop personal strategies for goal attainment were all part of their graduate school experiences. Upon graduation, American Indian MS students participating in this study reported feeling changed as individuals and often questioned the degree to which the content they had learned would apply to their cultural settings.
Faculty also reported significant challenges working with AIAN students.26 A desire for uniformity in the availability to all students and the maintenance of academic and professional standards tended to override efforts to provide individualized, culturally relevant instruction and advisement to AIAN students. For these reasons, Bridge project components were developed to support development of culturally competent advisors. Native worldviews and experiences were incorporated into a program of faculty development guided by tribal elders, medicine people, and spiritual leaders and were implemented in both academic and AIAN settings.
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CULTURAL GUIDANCE |
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Obtaining an advanced research degree is a critical component of scientist development. However, another goal is holistic health for Bridge scholars whose sense of AIAN identity is enhanced, not sabotaged, by their educational and professional aspirations. Medicine people and spiritual leaders help their clients preserve and nourish a balanced, healthy life-way.28,29 We thought that a healthy foundation would enhance the well-being and holistic energy and synergy of the group as well, as they encountered the everyday trials, challenges, and rewards of working on this project. To provide this base, medicine people and spiritual leaders serve as project consultants.
Connections with elders and medicine people or spiritual leaders were made in a variety of ways. The project director invited participants of an urban AIAN elder service providers group to take part. Three individuals subsequently created the programming for a Grandfathers and Grandmothers Supporting Indian Nurse Scholars group. One grandmother continued her participation with a part-time appointment that combines clerical and receptionist, student support, and community liaison activities. Her duties include welcoming and supporting students when they cross over to the doctoral program. Medicine people and spiritual leaders were already working with the University of Oklahoma, were friends of faculty, or were informally nominated by their tribal community. The family of 1 AIAN academic consultant stepped forward to participate.
AIAN academicians provide intertribal and national perspectives. Nurse scientists and student services professionals experienced in supporting AIAN students in high-stakes, competitive academic environments are represented in the consultant group. As a group, the AIAN consultants were part of an earlier wave of students who successfully negotiated the higher education system in relative isolation and then thrived in their careers, even as they maintained their AIAN heritage and identities. They serve as role models to Bridge scholars simply by their presence and in the telling of their personal stories. They actively advise students to partake of the academic and AIAN worlds to foster academic success and to enhance AIAN identity.
The AIAN Nursing Science Bridge holds an annual retreat to bring students, faculty, staff, medicine people and spiritual leaders, elders, and AIAN consultants together. Past retreats have been held at the conference center, tribal offices, and tribal college of the White Earth Band of Chippewa Indians in Mahnomen, Minn. Future retreats are planned in Oklahoma.
For AIAN participants, the retreat is a chance to return to the comforts and ways of home. For non-AIAN faculty and staff, the retreat is a cultural immersion experience that introduces and expands knowledge and understanding of their AIAN students’ life experiences and aspirations as nurse scientists.
The project director develops the formal retreat agenda in consultation with others on the project. Medicine people and spiritual leaders use traditional ceremonies and prayers to conduct the retreat. Elders remind everyone to use their AIAN manners. They begin Talking Circles to facilitate acquaintance among Bridge participants and to center each participant’s presence. Bridge scholars, faculty, and staff become learners as elders teach about traditional ways, describing health, child rearing, and educational experiences; food (rabbit snares, pemmican); ceremonial materials (knicinik); and handcrafts (especially sewing). Discussion of educational and research topics proceeds in the AIAN-centered, AIAN-surrounded retreat atmosphere, the essence of which will then be carried back to the academic world.
Project evaluation data, collected annually or at the conclusion of the retreat, provide some insights into the impact of cultural guidance activities. Deliberate inclusion of enhanced cultural understanding as a goal for everyone involved in the project was identified as a strong feature of the retreat. Participants rated activities with medicine people and spiritual leaders (smudging, prayer, individual consultation), AIAN academic consultants (presentation and advisement), and tribal elders (stories, crafts, presence, and guidance) at the retreat and in other settings as "helpful" or "very helpful." Faculty and administrators felt that involvement of the community showed a serious commitment to the success of the program. They reported that, with each retreat, they felt a greater depth of understanding and more connection with the AIAN community. Spontaneous interactions and a relaxed atmosphere contributed to memorable and useful experiences. Elders expressed appreciation and gratitude for being included in the project. The daughter of one elder (who had never had the opportunity to attend school) said that participation was her mother’s opportunity to shine as she encouraged Bridge scholars in their educational efforts.
The retreat was originally planned as a faculty development activity. Students suggested that they also take part. They were eager for the cultural connectedness that the activity provided, as well as the opportunity to meet faculty and staff from all project schools. Students identified personal guidance and encouragement from the AIAN community, collaboration in development of their research projects, and advisement about the doctoral program application as especially beneficial.
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TEACHING–LEARNING SETTINGS |
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TOPABSTRACTINTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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Research During the MS Program
At MS partner schools, the goal is to enhance research capacity. Schools with the MS as the highest degree tend to be less research intensive. The institutional goal of enhancing research capacity is designed to ensure that Bridge scholars obtain early research experience that positions them for competitive doctoral program applications. The research strength of the PhD school is used as the springboard to enhance research capacity at the MS school.
Research partnerships among faculty at MS and PhD schools are the key to development of enhanced capacity. A senior nurse scientist serves as liaison between researchers at partnership schools. The nurse facilitates research partnerships by assisting MS partner faculty to articulate programs of research, connect with established researchers at the doctor institution, and use research infrastructure at the doctoral university that is available to him or her. Faculty research interests and accomplishments at partner schools are linked by work on common projects as opportunities for collaboration arise or are developed. Because of the research priorities at both schools and their proximity to AIAN communities, many partnerships focus on health disparities research. As the research partnerships mature, they will serve as ideal sites for mentored student research.
In addition, student research experiences include a structured program focused on acquisition and refinement of skills for clinical science. These include use of literature search tools and bibliographic management systems, facility with data management and statistical analysis programs, and policy and procedure for working with human participants in research.
Research activities are discussed at the retreat with medicine people and spiritual leaders, elders, and AIAN consultants. Specific areas of investigation are approached from the points of view of the scientific community and the received knowledge held by AIAN people. In this way, the rigor of science is combined with traditional understanding to produce integrated perspectives on the health problems under investigation.
Doctoral Advisement
The number of nurses with earned doctoral degrees is so small that few schools have any experience guiding AIAN students through the PhD process. This is true even for faculty whose research programs are focused on health disparities. AIAN faculty have personal experience with doctoral education, but very few have advised other AIAN students to doctoral degree completion. For these reasons, the goal at the PhD school is to prepare faculty for informed and effective doctoral advisement of Bridge scholars. Successful guidance and advisement of AIAN students at the MS schools is the strength of this initiative.
RAIN, INSSP, and AIAN consultants make formal presentations at the retreat to share the wisdom that they have gained through experience working with students. Faculty from the PhD school become personally acquainted with RAIN and INSSP staff to facilitate direct links to informed consultation about issues related to Bridge scholar progression. Faculty and administrators in key positions at the PhD school (e.g., Director of Graduate Studies, member of the Doctoral Admissions Committee) take part in project activities. The Bridge then becomes a means to engage the doctoral faculty as a whole in the education of future AIAN nurse scientists. The circle of involvement is extended by the presence and activities of elders at the PhD school. In individual and small group settings, they have provided a personal perspective on the historic experience of AIAN people in educational and health spheres. Elders review and comment on Indian education and health news relevant to Indian nurse scientist training that is printed in tribal and national Native newspapers and other sources. With these efforts, Bridge scholars proceed in their scientific training in an academic milieu informed by and supportive of their career aspirations.
Visions for Research Programs
Students articulate an idea for their research programs as part of the Bridge application, and then initiate those ideas as part of their graduate school careers. Programs of study for the MS and PhD degrees, the Bridge research assistantship, and participation in professional and scientific societies provide foundational knowledge and skills. A common element of the envisioned research programs is a desire to generate new knowledge that can be used to eliminate health disparities among AIAN people. Specific areas of research are diabetes and elder health. Diabetes research programs range from an interest in primary prevention at individual and community levels (e.g., obesity prevention) to treatment of complications (e.g., kidney transplants). Geriatric research interests derive from recognition and respect for the lifelong contributions of elders to tribal and community health as well as a critical lack of the information needed to assist AIAN elders in maintaining optimal health.
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A CADRE OF AIAN NURSE SCIENTISTS |
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TOPABSTRACTINTRODUCTIONBRIDGES TO THE FUTUREJOURNEY TO SCIENCECULTURAL GUIDANCETEACHING-LEARNING SETTINGSA CADRE OF AIAN...References |
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Acknowledgments |
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With great sadness, we report that Roxanne Struthers died on December 10, 2005. Her work and example continue to motivate and inform our efforts.
With respect and honor, we thank the elders, medicine people, and spiritual leaders, and the academic consultants who have guided our work. Our students are our inspiration.
Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Contributors
S. Henly drafted the article and coordinated contributions of other authors. R. Struthers proposed the activities for tribal community involvement. B. Dahlen served as academic consultant and facilitated elder participation. B. Ide was site coordinator at the University of North Dakota, and B. Patchell was site coordinator at University of Oklahoma College of Nursing. B. Holtzclaw acted as research liaison. All authors reviewed and commented on the article and participated in creation of the past presentations, proposals, and project reports on which it is based.
Accepted for publication January 11, 2005.
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References |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
