The first time the needle pierces the skin, it immediately hits crimson. It’s 9:15 in the morning at the Tribal Health Clinic in St. Ignatius and nurse Candice Brown draws blood from her first patient of the day.
She grasps the woman’s arm with her hand, holding it with the steadiness and precision of a professional but with the care of a relative. As blood slowly fills the vial, Candice engages the woman in small talk.
She recalls the last time the patient came in, how hard it was to find her veins. The woman counters that she made sure to drink a lot of water before arriving. The conversation moves from the medical to the personal, as Candice inquires about a cousin of the patient’s. An enrolled member of the Confederated Salish & Kootenai Tribes on the Flathead Reservation, Candice often is well acquainted with the patients she attends to. As the conversation progresses and the blood nears the top of the vial, a calm has settled over the jittery patient. She chats with ease, the slight nervous stutter that filled her voice before the procedure no longer interrupting.
This talk is crucial to the checkup process at this tribal health center, where staff work to combine modern medical practices with Native American culture. While the woman is a regular of Candice’s, for some first-time patients these initial moments help establish trust and build an important relationship.
“A lot of times if the patient isn’t comfortable they won’t share things with us,” Candice explains later.
Crimson has now completely taken the place of clear and Candice pulls out the needle. The woman winces as Candice finishes, relaxing when a bandage is applied in the crook of her left arm.
As Candice eyes the warm vial through her thin rectangular glasses, the woman looks up at her.
“You got me on the first poke,” the patient says cheerfully.
Later, Candice talks of the interaction between nurse and patient. She emphasizes that each must be looked at as an individual. Her goal is to make each patient comfortable, even at times by unconventional means.
“They tell you not to hug your patients,” she says, “but there are some times when they are having a hard time and crying. They are my people. They are my cousins... So I’ve given patients hugs.
“Sometimes that’s all they want. They need somebody to tell them that it’s going to be OK.”
It may seem mundane, but this type of patient-provider interaction on the reservation was almost unheard of 20 years ago. Indian Health Service nurses were primarily white and often had little understanding of their patients’ culture and community.
“There were just very few Indian nurses on the reservation,” Salish Kootenai College President Joe McDonald says.
White nurses tried their best to accommodate the unfamiliar culture, but seldom saw success. Culture clashes would arise from differences in healing theories—what the provider thought was best for a patient’s health might conflict with the patient’s traditional values. Tribal customs could complicate even a routine procedure, as a patient’s concerned relatives would sometimes crowd the examination room in hopes of offering support and guidance, but sometimes making it harder for medical personnel to do their jobs efficiently.
“When there is a serious illness the whole family will come,” McDonald says. “They will all be here. If your uncle is sick, you just drop what you’re doing and you just come.”
In these cultural misunderstandings, McDonald saw an opportunity for SKC: to create a nursing program to produce exceptional nurses who specialize in work on Indian reservations.
McDonald explains that establishing the SKC nursing program was no easy task, motioning with the tired right hand of a 74-year-old that has been at the forefront of this Native American college’s rise over the last 33 years. He sits in his office in Pablo, looking out to the Mission Mountains. Two blocks from his office is the John Peter Paul Building, home to the college’s nursing program.
Securing approval from the state nursing board and funding for the program were challenges, McDonald says. But the biggest obstacle was recruitment. In the early 1990s, few Indians were interested in nursing. And the program lacked the reputation it has today, which made it difficult to attract interested students.
Of the few students who chose to attend many were not prepared for the strict regimen of the associate of science nursing program. But the college wouldn’t budge on the rigors of the classes. In real-world situations, nurses have no time for hesitation. Choices must be decisive. There’s no gray area and there’s no room for error.
“I would get some complaints early on about students having trouble with the program,” McDonald says. “But when you’re lying there on a gurney and a nurse is about to put an IV in your arm, you don’t want any gray.”
Those first students survived and thrived and 19 years later the program is the number one producer of Native American and Alaska Native nurses in the country, according to the college. Today the SKC nursing program boasts close to 150 students.
•••
Candice Brown knew from an early age that nursing was her calling. She just wasn’t always sure that the dream was within her reach.
As the daughter of a Navajo father and Salish-Kootenai mother, Candice split time between Montana and Northern Arizona. The moves were frequent, and sometimes tough. The toughest test, however, began the day her brother died.
On Dec. 8, 2000, Candice’s brother Victor killed himself after years of battling paranoid schizophrenia. His death sent Candice down a dark path. She became secluded and depressed. At school in Arizona she had already been struggling, having trouble making friends. She says other students were part of cliques and ridiculed her. When Victor died, the torment from fellow students didn’t stop. Her depression deepened. Teachers didn’t help, she says, because they didn’t recognize the depth of her pain. To them, Candice was acting out. It became almost unbearable.
“I got to the point where I just didn’t want to be here anymore,” Candice says as her voice drops slightly. But then she got help. Through the encouragement of her parents, Candice went to counseling. She talked to people about her feelings. She journaled. She researched depression. And she started to get better, eventually conquering her depression and emerging with what she says was a new appreciation for helping others.
“I wanted to get through it so I could do something with my life,” she says.
Candice’s father, Preston Brown, says he noticed a change in his daughter after the death of his son.
“She wanted to dedicate herself to knowing how that could have been prevented and the whole subject matter of health services,” Preston says from his home in Arizona. “That pretty much gave her an incredible spark because it involved the death of a loved one.”
A determined Candice scratched and clawed her way through middle school and part of high school, before deciding to obtain her GED at age 16. She wanted to go to college to become a nurse and help people. She searched for a college that could teach her to how to prevent tragedies like her brother’s—one that would teach her to treat patients with both compassion and medicine.
Salish Kootenai College was a perfect match for Candice.
•••
It’s Tuesday morning in the John Peter Paul Building, and second-year nursing students gather in a lab. It’s the first class after a two-week end-of-the-quarter break. The 11 students are noticeably lively, all of them chatting and catching up after the vacation. The room exudes a certain “calm before the storm” quality. The talk is lighthearted and the students are loose, but this is sure to change as June graduation quickly approaches.
The majority of the students are of Indian descent, a few others are Caucasian and one is black. Lashinda McBride expects to soon be the second black graduate of the SKC associate of science nursing program.
As some of the students continue to talk, she checks up on Meti Man. Meti’s skin is tan and rough. With each breath his sculpted chest expands and contracts. Lashinda leans over and grabs his wrist. After looking at her watch, Lashinda says his pulse is 113 beats-per-minute, though that’s soon recalibrated to a more-normal 60 beats. Taking her stethoscope from around her neck, she then puts the buds in her ears and places the other end on Meti’s stomach to listen for his bowel sounds. She moves it around for several seconds, shrugs, and then takes the buds out of her ears.
“We all know what normal sounds like,” Lashinda says. “It’s the abnormal sounds we’re looking for.”
She guesses that nothing is wrong with Meti and says he should be fine. Meti would have breathed a sigh of relief and thanked Lashinda for the prognosis. But Meti can’t talk. He’s a computer-programmed dummy—one of three high-tech dummies that the SKC nursing program uses to train its students for real-world scenarios. It’s only through a combination of modern medical technology and rigorous cultural training that SKC prepares its nurses for the challenges of treating patients in Indian country, where medical resources are limited, cultures diverse, and chronic diseases like diabetes and alcoholism prevalent.
During the rest of the class the students take turns on Meti, along with his buddies Stan and Petie. They are instructed by the teacher what to listen for in the dummies’ lungs and bowels, all things they’ll do in the real world.
While learning to listen for cardiovascular abnormalities is a necessity for a nursing student, at SKC listening to patients and understanding their traditions and personal concerns is equally important. In other classes, students are taught about diversity, holistic care methods, and Indian culture. Twelve Native American studies credits are required of all students before graduation.
Those are the classes that help Lashinda. A Minnesota transplant who ventured to Montana after 15 years as a certified nursing assistant, Lashinda came out West after hearing about SKC from an eastern Montana relative. A city girl from Minneapolis, Lashinda had never had much interaction with Indians. Learning how to deal with different types of patients is crucial for Lashinda, along with the rest of the class, as studies show that 95 percent of graduates with SKC associate of science nursing degrees will work on a reservation. Lashinda plans to take a job in Deer Lodge.
Lisa Lackner is in charge of making sure each student learns the practical and cultural components of nursing. As the SKC director of nursing, Lackner emphasizes what she calls the four Cs. The first C stands for critical thinking — crucial in emergency situations. Then citizenship and communication follow. The fourth is what Lackner says makes the program unique — cultural competence.
The SKC curriculum is tailored to train nurses to work with Native American cultures, but it also underscores the importance of accommodating patients from any culture. That means talking with patients, asking the right questions and most importantly, listening.
By listening, nurses can learn which specific treatment is appropriate for each patient. If a nurse prescribes a regimen that a patient won’t adhere to because of a cultural conflict or misunderstanding, the nurse has done nothing for the patient.
Lackner teaches her students to throw out any preconceived notions about a patient. She instructs nurses to sit down with their patient and develop a plan together — one that improves the patient’s health while respecting the patient’s values.
“It may not be the ideal treatment plan you have in the back of your head,” she says. “But that may only be ideal for your culture.”
The majority of SKC graduates are familiar with Indian culture even before they enroll in the program. There is a sense of solidarity among the students, a connection to the community and to Indian traditions. That, combined with a rigorous nursing curriculum, helps SKC achieve its ultimate goal of putting more Indian nurses in Indian health care facilities.
•••
Candice doesn’t get the leisure time many 22-year-olds do. Monday through Friday she happily works with patients from 9 to 5. Once home in Ronan, she gets to work on further nursing studies. It’s been almost a year since she earned her associate’s degree, but school is still in her system. Now she’s taking online courses at home through SKC in its bachelor’s of science nursing program. She’s looking further down the road to the possibility of a master’s degree.
That could come from SKC if things fall into place. Due to budgetary and building deficiencies, McDonald says the school can’t yet field a master’s program, but would like to eventually. Currently the nursing department shares the same roof as the SKC dental program, which occupies the first floor.
With a master’s or doctorate, Candice would shift from dealing with individual patients as she does now to becoming someone who works on nagging medical problems prevalent on the reservation. These range from the diabetes that runs rampant on the reservation, to alcoholism and prescription drug abuse.
Statistics show what Candice sees every day in the tribal health center: An American Indian is twice as likely to be diagnosed with diabetes as a non-Indian, according to the U.S. Department of Health and Human Services. One in nine American Indian deaths is alcohol-related. And prescription drug abuse is a growing problem on Indian reservations.
But for Candice, these aren’t just statistics. They’re people she went to school with, people from her community. Every day, every patient who walks into the examination room brings her a step closer to her goal — an ambitious goal to be sure. Before she gets there, she has a lot more listening to do and a lot more learning.
“You see a lot of bad things here,” she says. “But the days when you see somebody come in and their blood sugars are where you want them to be... it just feels great. Because you’ve got them there. You helped them get there.”
Back in her office, Candice looks up at the clock, awaiting her 2 p.m. patient. He’s running a few minutes late, but she hears the shuffling in the hallway and quickly rises to greet him. The two exchange greetings as he walks into the examination room. Before entering, Candice reaches up and pulls a small yellow lever on the wall that sticks out like a flag. This tag lets people know the nurse is with her patient.
She enters the room with a smile, ready to talk, and ready to listen.