Are you looking for a nursing career that's different from the "same old same old?" One that offers variety, challenge and opportunities to work in many different parts of the country? A deeply fulfilling career that gives you a chance to make a real difference in addressing some of the nation's most serious minority health disparities? Then consider a career with the Indian Health Service (IHS).
There are more than 560 federally recognized American Indian and Alaska Native tribes located throughout the United States. The Indian Health Service, a federally funded agency within the Department of Health and Human Services, is the primary health care provider and advocate for approximately 1.9 million of the nation's 3.3 million American Indian/Alaska Native (AI/AN) people. About 57% of AI/AN people in the U.S. depend on IHS for a wide range of health care services, including hospital care, clinical care, dental and pharmacy services.
These are particularly exciting times for nurses to pursue careers in the Indian Health Service. President Obama's fiscal year 2010 budget authorized one of the largest IHS funding increases in 20 years. As a result, the agency now has a $4.03 billion operating budget directed at supporting and improving health care services, improving health outcomes, promoting healthy communities and addressing health disparities. Last year the IHS received a $500 million allocation of American Recovery and Reinvestment Act funds to help pay for new health care facilities, health information technology, medical equipment and other improvements in the delivery of health care to AI/AN communities.
Although the IHS as we now know it was established in 1955, earlier efforts to provide some type of federally funded health care for Native people date back to the 19th century. By 1921, the Snyder Act authorized the use of federal funds to provide health services to federally recognized tribes, which are sovereign nations that have a government-to-government relationship with the United States. The Snyder Act approved funds "for the relief of distress and conservation of health. . . [and] . . . for the employment of . . . physicians . . . for Indian tribes throughout the United States.
"Today the Indian Health Service provides a comprehensive system of health care services to AI/AN people living on or near tribal reservations, in rural communities and in urban settings. Headquartered in Rockville, Md., just outside the nation's capital, the agency has 12 local area offices across the country, mostly in the Western U.S. and Alaska. The IHS operates 31 hospitals, 63 health centers, 30 health stations and 34 urban Indian health projects.
During the 1970s, landmark legislation such as the Indian Self-Determination and Education Assistance Act gave tribes the option of contracting with IHS to operate and manage their health care services themselves, rather than receiving services directly from the agency. As a result, there are currently 14 hospitals, 240 health centers, 102 health stations and 166 Alaska village clinics that are run by tribal governments.
Through both federally operated and tribally contracted health programs, the Indian Health Service's goal is to ensure that all AI/AN people throughout the U.S. can receive health care that is accessible, comprehensive and—most importantly—culturally acceptable.
"The thing that is distinct about working for the Indian Health Service, besides the fact that it is a federal agency with a direct clinical service delivery mission, is the fact that the American Indian/Alaska Native people still have much of their [traditional] culture intact," says Carolyn Aoyama, CNM, RN, MPH, the agency's senior consultant for women's health. "American Indian culture is very different from the dominant culture." For non-Native nurses, she adds, having the opportunity to learn about and work within a culture that is so different from their own can be a tremendously enriching experience.
Culturally appropriate nursing care can play an important part in helping to eliminate the severe health disparities that are rampant in AI/AN communities. According to IHS statistics, the life expectancy of AI/AN people is almost five years shorter than that of the general U.S. population, and they have significantly higher mortality rates from tuberculosis, alcoholism, diabetes, automobile accidents, unintentional injuries, homicide and suicide.
"Diabetes is the predominant diagnosis that we see," says IHS nurse Devon McCabe, RN, a member of the Navajo nation in Leupp, Ariz., who works as an ICU supervisory clinical nurse at the Gallup Indian Medical Center in Gallup, N.M. "My goal is to get these patients out of the hospital and [help them stay] healthy. I stress to my staff that educating our patients is a top priority. Patients need to be self-aware about their diseases and understand their diagnosis."
The Indian Health Service currently has a nursing workforce of more than 2,500. But like many other health care employers that have been impacted by the nursing shortage, it has struggled to recruit and retain nurses, in in-patient, outpatient and public health/community health settings. Last year the agency's overall nursing vacancy rate was 26%—compared to 21% for physicians and 11% for pharmacists. Therefore, nurses interested in exploring careers in the IHS will find great demand for their skills and an exciting variety of opportunities to choose from, especially if they are willing to work in rural, medically underserved locations.
"Here on the Navajo reservation, hiring is one of our top priorities," says Jeannette Yazzie, BSN, RN, nurse consultant for the Navajo Area IHS office in Window Rock, Arizona. "I have a nurse recruiter at each one of our facilities. We're just in the process of reestablishing a region-wide recruitment and retention group which will include not only nursing staff but also physician and pharmacy staff. Our greatest need for nurses right now is in OB and ICU. Medical-surgical nurses are always needed."
The IHS also needs more advanced practice nurses, including nurse practitioners, nurse-midwives and nurse anesthetists, adds senior national nurse recruiter Celissa Stephens, MSN, RN. "The vacancy rate for APNs has been going up every year for the past four years," she notes. "Advanced practice nurses have a lot of autonomy and responsibility within the Indian Health Service, and in general the risk status of the population and the patients that they're going to be serving will be higher."
IHS nurses have the option of working either for the agency or for tribes. Nurses hired by tribally operated facilities are employees of the tribes, which typically determine their own salary levels and benefits packages. Nurses who work at IHS-run facilities are employees of the federal government and can choose to be either civil service employees or members of the U.S. Public Health Service Commissioned Corps.
According to Stephens, salary rates for federally employed IHS staff nurses are competitive with the national average for the private sector. Nurses will also find plenty of opportunities for professional growth, including training programs, education programs and leadership development.
The agency also offers a loan repayment program as well as a scholarship program to assist staff members who wish to advance their professional education. Each year the IHS awards scholarships to help AI/AN nurses complete their bachelor's or master's degrees while maintaining their full salary and benefits. "That's how I earned my master's degree," says Stephens.
If you thrive on versatility and variety, rather than doing just one type of nursing in one location, then a career with the Indian Health Service is for you. IHS nurses typically handle a wide range of medical and public health situations, and they must be open to performing duties that fall outside those of traditional nursing jobs at private sector health care facilities. Plus, working for the IHS gives you the opportunity to move around the country and work with a variety of different tribes and cultures.
"On most of our reservations, when we're looking for OB nurses for example, we [want] them to be able to work a whole range [of nursing functions]," explains Yazzie. "We want them to be able to [provide care to the mother] before birth, after birth, and then provide care to the baby."
In her 25-year career with the IHS, Yazzie has journeyed both geographically and professionally. "I initially started as an ICU nurse in 1983," she says. "Being Navajo and growing up for part of my life on the reservation, I always knew I wanted to work there and assist my people in whatever way I could. Working for the IHS has been very rewarding for me. It has taken me many places and given me numerous opportunities [to advance in my career]."
Over the years, Yazzie has worked in Washington state with the Yakama tribe, at the Whiteriver Indian Hospital on the White Mountain Apache reservation and at Indian Health Service facilities in Phoenix, Ariz., and Alaska.
Similarly, Stephens, who is a member of the Choctaw nation of Oklahoma, has worked for the IHS since 1989 and has held a variety of positions, including ICU nurse, manager of a med-surg unit, clinical nurse specialist, clinical nurse consultant and chief nurse consultant.
For nurses who love the outdoors, the IHS offers opportunities to work in some of the country's most beautiful, unspoiled natural settings, from the spectacular landscapes of Alaska to the Big Sky Country of Montana. In Arizona, for example, there are plenty of activities for an outdoors person, including walking, biking, hiking and many national parks and monuments to explore. If, on the other hand, you're someone who prefers to live and work in a city environment, there are IHS urban Indian health programs in metropolitan areas like Chicago, Denver, Dallas, Los Angeles, Minneapolis, San Diego, Boston, Milwaukee and Tucson.
Unfortunately, many non-Native nurses fail to even consider the possibility of pursuing a career in the Indian Health Service because they mistakenly believe that only American Indians and Alaska Natives are eligible to work for the agency. This perception, though common, is not true. While the IHS is federally required to give hiring preference to AI/AN people first, nurses of all races and ethnicities are encouraged to apply. Currently, only about half of the IHS nursing staff is American Indian or Alaska Native (see below).
Aoyama is an example of a non-Native nurse in a leadership role within the IHS. "For me it's been fabulous," she says. "I love working in this agency. It's a mission-driven organization that is very clear about its purpose. There's never any mistake about what the purpose of your work is and who you are serving, and I thrive in organizations like that. I find the people to be very generous in helping me understand the culture."
Being open to learning about, adapting to and embracing AI/AN culture is definitely a key requirement. Yazzie says that the non-Native nurses she hopes to recruit are always offered the chance to come and visit the Navajo reservation, or any other reservation, because the culture and lifestyle is so different from the majority culture.
"It's not like the big city," she warns. "Some of our reservations are pretty isolated and remote. Some people [who have never been to a reservation] are quite shocked at the distances we [have to] drive and the fact that we still have homes with outdoor [bathroom] facilities, no indoor plumbing and no electricity. People will ask me how far away the nearest Walmart is and I tell them that it's 60 miles away.
"The realities of reservation life are nothing like what is portrayed in Hollywood "cowboys and Indians" movies, Yazzie emphasizes. "I think some people out there in the world still believe—and I'm hoping that this stereotype is lessening—that Native Americans are like the people they see on their television set," she says. "[Sometimes non-Native nurses come into IHS] thinking that they are going to 'rescue' us. We certainly don't need to be rescued."
Stephens agrees. "Despite the Anglo cultural view that not having [modern amenities like] heating and plumbing is a detriment, these communities choose to maintain their lifestyle and culture. Another benefit of working for the IHS and working out in the field is that you have the opportunity to be embraced by the community. You learn so much about that community."
For some IHS nurses, learning about AI/AN culture and traditions may also mean learning a new language. Some tribes maintain their original languages to keep this part of their cultural heritage from disappearing.
"[Language barriers] are definitely a concern that some [potential nursing employees] have," says Yazzie. "I'll have people call me and talk about wanting to come and work with the Native American population, and oftentimes they [ask] if they have to be Native and do they have to speak the language."
"I remember when I worked with the Navajo nation in 1975," says Aoyama. "I had to have an interpreter because I couldn't speak Navajo. It's very different and [extremely difficult to learn]. You [really] have to learn the language as a child."
Even though the IHS is working to attract more nurses from diverse racial and cultural backgrounds into its workforce, it will always have a particularly strong need for more American Indian and Alaska Native nurses who are culturally knowledgeable and deeply committed to improving the health of other AI/AN people, especially in their own tribal communities.
"If a [non-Native] nurse wants to work for us, they have to be open-minded and want to learn more about people in general," says McCabe. "The people that I care for are part of my tribe and that's the catalyst for what I do."
To learn more about nursing career opportunities in the Indian Health Service, including current job openings, visit www.ihs.gov/MedicalPrograms/Nursing.