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 Serving the UnderservedSometimes the path to financial aid ends up leading minority nurses to rewarding careers serving the neediest of populations By David H. Chasey Sandy Schuyler, R.N., associate director of the Milwaukee Indian Health Center, was born and raised on the Oneida Indian reservation in Wisconsin and left in the 1970s to pursue a career in nursing. “I started my nursing career in 1974 when I became an LPN,” she says. Schuyler (pronounced Sky-ler) then set her sights on becoming a doctor. After completing two years of medical school, she decided to return her focus to raising a family. “Once I got my family settled again, I went back to school and got my B.S.N.,” she notes. “I started working here [the Milwaukee Indian Health Center] shortly after my graduation.” Both Schuyler’s medical school and nursing education were financed through the Loan Repayment Program of the Indian Health Service. The program, and others like it, offer monetary assistance to aspiring nurses in exchange for serving in areas that desperately need health providers. What many nurses are finding, however, is that this exposure to communities that are displaced, low-income or in other ways underserved, is leading them to fulfilling long-term careers. While being paid a normal salary, Schuyler fulfilled her loan repayment obligations at a one-to-one rate: one year of employment paid off one year of educational loan obligation. Schuyler’s first two years of employment fulfilled her two years of medical school obligation and her second two years fulfilled her loan obligation for the two years of nursing education leading to her B.S.N. After both of her loan obligations had been satisfied, Schuyler decided to continue her career at the Milwaukee Indian Health Center and is now an activist in the health care cause of urban Native Americans. “Urban Indian centers are pretty much the forgotten latchkey children of the health service world, not only in the IHS but in all of health service,” she describes. “We’re even the forgotten children of the tribal nations within each state. There are only 34 urban IHS centers in this nation. The Indian Health Service has recognized the need for urban Indian health care and they now seem to be giving it high priority.”
During that time, King set her sights on a nursing career and, in 1978, received the first of two scholarships for nursing education, an NHSC scholarship that enabled her to earn a B.S.N. in 1982 and become an R.N. She then decided to join the NHSC as a commissioned officer. Her status as an NHSC officer and a federal employee enabled her to receive a second, long-term training scholarship from the bureau. Through this second scholarship King earned a master’s degree and became a family nurse practitioner. King’s scholarships brought with them a combined commitment to work for over seven years in designated underserved areas. Her undergraduate degree, earned through the NHSC Scholarship Program, had a one-for-one service commitment, while her graduate degree, earned through a BPHC Long-Term Training scholarship, had a two-for-one commitment. King says that her salaries fulfilled both program commitments and were competitive with or exceeded the national salary averages. In her current position, King helps other scholars choose the designated sites for fulfillment of their service obligations, facilitating matches between the scholars’ individual skills and personality traits with the needs of available sites. “Once they’ve completed their education, we help the scholars with their matches. It’s like a support unit.” King’s own richly varied work experience has prepared her well for this advisory role. An African American from Washington, D.C., she has worked as a psychiatric nurse at Saint Elizabeth Hospital, Washington, D.C.; as a nurse practitioner in Zaire during the 1994 UNICEF Rwandan relief effort; and in a variety of specialized settings that include medical-surgical, pediatrics and ob/gyn. King fulfilled her first scholarship obligation as a staff nurse at Tuba City Indian Hospital in Arizona, on a Navajo and Hopi Indian Reservation. “Coming from the District of Columbia, that was quite a culture shock but I fit in pretty well dealing with another culture, because their needs weren’t that different than mine. I understood what some of the cultural problems could be.” King continues, “I think the training I had in Indian health helped me more than anything. It was different, but different is not bad. It prepared me for all of the other things that would follow. That was the first time I had ever worked with a totally different population.” Return on InvestmentArneatha Martin, R.N., is an African American whose dedication to serving the underserved—focused within her home community in northeast Wichita, Kan.—serves as a beacon signaling the range and depth of possibilities that can spring from receiving federal financial aid. Martin’s career path began with a boost from a Kennedy era health care program: “In the early ’60s I was really fortunate to be a part of President Kennedy’s manpower development program,” she recalls. “They were offering to send people to LPN school.”
Martin became an LPN, later earned her bachelor’s degree and became an R.N., then earned a master’s and soon became an advanced registered nurse practitioner. “I was working my way up the system, with the help of a whole lot of people,” Martin remarks. Now, she is helping others through the Center for Health and Wellness. CHW is a state-of-the-art primary health care facility that emphasizes prevention and wellness education for underserved clients. The center is the culmination of an organizational tour de force orchestrated by Martin and her associates, including the Wichita Black Nurses Association (see More Than Good Enough). The experiences of Martin, King and Schuyler demonstrate the return that government programs and society receive from their investment in scholarship and loan repayment programs. For her part, Martin attributes much of her success in serving the underserved to having a master’s degree in nursing. “I believe that an advanced degree in nursing gave me the additional skills that I needed to be taken more seriously,” she affirms. The agency which assists many minority nurses in reaching this level is the Bureau of Primary Health Care, an agency of the federal Health Resources and Services Administration that has the mandate of providing primary health care to underserved and vulnerable populations. The National Health Service Corps, a program of the BPHC, assists underserved communities through the development, recruitment and retention of community-responsive, culturally competent primary care clinicians dedicated to practicing in designated Health Professional Shortage Areas. For the nurse pursuing a career of service to the underserved, the key words are recruitment and retention. The NHSC offers substantial incentives for the recruitment of nurses committed to serving the underserved and for their retention in Health Professional Shortage Areas. The BPHC also has other programs with similar aims, offering similar incentives. What this all adds up to are some very generous scholarship and educational loan repayment programs for this career path.
The Indian Health Service, completely separate from both the BPHC and the NHSC, is a sister agency of the Health Resources and Services Administration and has a health care mandate that in many ways mirrors that of the NHSC. Moreover, the IHS offers similar financial/ educational incentives to nurses and other primary health care providers. However, the population served by the IHS is restricted to Native Americans and Native Alaskans. “I think the opportunities are incredibly attractive and I think the reason that they are is that they really appeal to why most people want to become a caring professional,” says Assistant Surgeon General Donald L. Weaver, M.D. “That is, to make a difference in the lives of individuals.” For government agencies, loan repayment and scholarship programs represent incentives for the recruitment and retention of primary health care providers in underserved areas. “It really is an incentive to attract people to service to the underserved,” Weaver adds. “Our hope and dream is that once they see how rewarding a practice like this can be, how appreciative their patients are, see that they’re helping to achieve our bureau’s vision of 100% access and zero health disparities and how they are a part of that vision, we’ll have them hooked for a long time, hopefully for the rest of their careers.” Loan Pursuits
While many nurses are eventually hooked by the rewards of practice, most are initially attracted to the loan repayment component of these programs. “The NHSC Loan Repayment Program repays loans incurred by health care professionals who make a commitment to serve in an underserved area in primary health care,” states Sonia Leon Reig, director of the Division of Scholarships and Loan Repayments at the Bureau of Primary Health Care. LRP participants assume a two-year service commitment minimum, which can be extended up to five years, as long as they owe on their educational loan. “We have primary care nurse practitioners involved in this program and certified nurse midwives,” Reig continues. “This program pays up to $25,000 per year with an additional 39% that is given per year for tax liability.” The LRP has two elements: 1) the application of the individual primary health care provider, e.g., nurse practitioners and certified nurse midwives, and 2) the application of the health clinic with which the applicant has contracted to serve. The clinic must be in a Health Professional Shortage Area of greatest need and show itself to be both economically and clinically viable. The individual applicant must provide: 1) a copy of an employment contract between the applicant and the health center, 2) proof of his or her educational loan(s), and 3) a copy of his or her nursing license. Both parts of the application must be approved by the NHSC. Once working at the designated site, the nurse’s salary is paid by the health facility. Says Reig: “The salary is totally separate from the loan repayment and is competitive within the area.” The BPHC also administers the Nursing Education Loan Repayment Program, specifically for professional full-time clinical nurses. “We pay 60% of the principal and interest of their nursing education loan,” Reig states. The minimum work commitment is two years and can be renewed year to year after that point. “Most of the nurses going into the program have a two-year contract with us,” she adds. There is no site selection by the applicant. The BPHC designates the site where the applicant will serve, targeting public hospitals. “We have a list of areas that qualify, again primarily shortage areas.” The downside of the NELRP: It is currently plagued by a shortage of funding. Reig details: “We have $2.1 million for this program on a yearly basis. We had 812 applicants last year and were only able to fund 117. We now have a work group of internal nurses as well as public health nurses throughout the nation, the American Nurses Association and the American Association of Colleges of Nursing. We are now trying to see how we can restructure this program to meet more needs,” and raise the amount of funding. Still another funding option for minority nurses is the State Loan Repayment Program, in which 32 states participate. Through this arrangement, the BPHC confers a grant to a state organization that administers the program. “The state organization can be an area health education center, a primary care association, a state rural health office, a health department—it runs the entire gamut,” says Reig. The organization then selects individuals from the state for the loan. As with the bureau’s other loans, the recipient of the SLRP also commits to a minimum of two years of service. Reig notes that there are other similarities, as well. “The Health Professional Shortage Areas are the same except that, for the SLRP, they actually are not the areas of greatest need. They are any Health Professional Shortage Area.” Several agencies also offer scholarships, not based on academic performance, but on an individual’s commitment to serve the underserved in primary health care. Such a program is the NHSC Scholarship Program, open to nurse practitioners and certified nurse midwives, as well as other primary care providers. The scholarships pay for tuition and fees, books and supplies, and equipment for up to four years of education, according to Reig. The service commitment requires one year of service in a federally designated Health Professional Shortage Area of greatest need for each year of scholarship. The minimum service obligation period is two years. Given its limited funding, the NHSC Scholarship Program is very competitive. “We received 2,114 applications in 1998. We funded 326,” says Reig. Applicants are systematically rated and scored on their level of commitment to serving the underserved through a two-pronged application process, a written questionnaire and an interview. The questionnaire is assessed and those who achieve a given level of scoring go on to the interview phase (1,000 of the 2,114 in 1998). The interviewer systematically assesses and scores the candidate’s likelihood of staying committed to primary health care service to the underserved. The scores are averaged to determine scholarship recipients. Reig summarizes: “We start funding people based on the scores that they receive and then we fund as many as we can given our money. Last year we had $30.1 million and we were able to fund 326 applicants, including 10 nurse midwives and 76 nurse practitioners.” Both those who dole out such funding and those who receive it agree that more economic support is needed for these programs. Given the proven success of loan repayment and scholarships in attracting minority nurses to chronically underserved areas, state and federal officials might do well to extend their capacity and thus draw even more nurses down this fulfilling career path. David H. Chasey is a free-lance writer based in Pittsburgh. He last wrote for MN on the subject of parish nursing. Editor’s Note: Following the completion of this story, we learned that after 25 years of service to underserved and uninsured people (Indian and non-Indian alike), the Milwaukee Indian Health Board, Inc., is closing its doors due to lack of funds. “It’s a very sad day for us,” comments Schuyler. “When we walk out that door [on April 9] at 5 p.m., it will mark the end of an era.” Schuyler maintains hope for Indian health care in Milwaukee. “It’s going to take a lot of hard work to reestablish, but I’m determined to do everything that is humanly possible to return with service to the population. We will need a lot of good thoughts and prayers.” |
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