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(Many Paths)
An Online Newsletter Celebrating Native America
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Culturally Congruent Care: Salish Kootenai College's Registered Nursing Program
by Dina Horwedel - Tribal College Journal

Registered nurses (RNs) are one of the nation's top in-demand occupations. The Bureau of Labor Statistics expects the field to grow from 3 million in 2019 to 3.3 million in 2029, an increase of 7%. New registered nurses are also needed to replace the 175,900 who are projected to retire over the next seven years. For Native communities, the demand for RNs is particularly important. Often located in rural areas where there are already shortages of medical facilities and healthcare personnel, Native Americans suffer from chronic conditions such as diabetes and high blood pressure at disproportionate rates. Native RNs are the key to providing patients with culturally competent and vital care such as wellness check-ups, vaccines, and inoculations, ensuring their communities' overall health.

Salish Kootenai College (SKC) has stepped up to become the first tribal college to offer a four-year registered nursing degree program. It welcomed its first student cohort in the fall of 2020— the 200th anniversary of the birth of nursing pioneer Florence Nightingale and the World Health Organization's Year of the Nurse. There was no better time to launch the program—and not just because of Nightingale's birthday and the pandemic. Lisa Harmon, PhD, RN, and certified nurse educator (CNE), is the chair of SKC's nursing program and a veteran nurse of 43 years. She says the impetus for the program was hospitals phasing out nurses with associate's degrees in Montana and across the nation because many studies show that nurses with a bachelor's degree make fewer errors.

The Institute of Medicine (IOM) is a nonprofit think tank chartered as a component of the National Academy of Sciences, serving as the nation's adviser to provide unbiased, evidence-based, and authoritative information and advice concerning health and science policy to lawmakers, professionals, leaders in every sector of society, and the public at large. The IOM partnered with the Robert Wood Johnson Foundation in response to the institute's findings that healthcare errors rank in the top ten as leading causes of death in the United States. The two organizations published The Future of Nursing, a report that resulted from a study, a review of scientific literature about the nursing profession, and from a series of public forums that gathered insights and evidence from a range of experts. The report charged the healthcare industry to create reforms to provide higher quality and reliable care—starting with nurses. It also set out to reduce errors by coupling the educational background and preparation of nurses and recommending an ambitious goal: by 2020, 80% of nurses would have a Bachelor of Science in Nursing (BSN). "It makes sense, because nurses are the largest sector of healthcare professionals and are at the bedside of patients more than any other healthcare professional," says Harmon.

Those programs and initiatives "gave hospitals and states a clear idea of where they wanted to go with their hiring practices," Harmon explains. And it galvanized her determination to create a four-year nursing program at SKC for financial and ethical reasons. She believes there is too much information to cram into a two-year program and has been "a huge proponent of bachelor's degreed nurses forever." SKC's associate's degree in nursing program takes three years. "Students can continue for another two years to earn the RN-BSN completion degree for a total of five years of schooling— but a lot of federal financial aid would only cover the students for the first degree earned, which would have been the associate's degree, and then there was no way to get the bachelor's degree," Harmon says.

She believed SKC needed an RN program because big healthcare systems like Indian Health Services (IHS) require a bachelor's degree to apply. "Some IHS providers in very rural areas, such as Browning, Montana, will hire students with an associate's degree. It is only after the student has had one year of experience, but preferential hiring for these big systems is with a bachelor's degree," she maintains.

Harmon was intent on offering a BSN program to students at SKC because a condition of receiving an IHS scholarship is agreeing to work for the agency for a set number of years after graduation. If students do not, they must pay back the scholarship. With IHS now requiring a bachelor's degree, she says that it no longer made sense to offer a program that fails to meet the industry standard.

Harmon was concerned that students would infer that SKC didn't believe Native students could handle the program if they did not offer a four-year nursing program at a tribal college. She cites many success stories and a strong desire to give back to the community. "You can't generalize, but our Native students see our patients as the whole person… it is a beautiful [cultural] mindset," she says. A lot of SKC students are inspired to discover their greater purpose, which contributes to their academic success. When students "have that altruism…the sky is the limit."


The four-year program at SKC is a direct admit model. Interested students take a pre-admission exam and must earn a certain requisite score to demonstrate a strong probability of success in their first college class. The cohort-based program has only one point of entry. Once the students are admitted to the program, they do not take general education classes and then wait to take nursing classes in years three and four, like students in other state institution programs. "That model doesn't match our student need. If you are a parent and you have children, you can't go to a college town, take classes, and sit and wait to get into nursing classes for years three and four," Harmon says.

The cohort model is a good match for the tribal college because SKC students are community spirited. "Students learn best in groups, and they are place-bound for the most part," Harmon says. This positive environment is aided by the fact that their program does not over-admit. "We have clinical spots for every student. These nursing students feel much more comfortable in a group; they love studying together. They are going to go through the whole four years together and will help each other through it… it's more collaboration based," Harmon explains. SKC also has a lot of older or non-traditional students coming back to school, and the cohort model helps cultivate a sense of belonging and eases their fears. The cohort model isn't the only difference. The curriculum differs from state institutions in that SKC weaves cultural competency into instruction. Harmon describes it this way: "One of our core cultural learning outcomes is to understand what culture looks like from the lens of healthcare. Every class we are writing for our four-year Bachelor of Science in Nursing program will be a collaboration between Western medicine and Native ways, which will help them provide culturally congruent nursing care."

When writing the pain management curriculum, Harmon interviewed tribal nurses about Indigenous methods of managing pain and worked with the tribal librarian to find archival information about the practice. She says literature abounds with instances showing that culturally congruent care gives patients better healthcare outcomes, and "finally the nation is giving attention to the importance of cultural knowledge rather than minimizing it."

Culture is considered in the program right down to anatomy studies, typically done with a human cadaver. SKC is the first college in Montana to utilize a synthetic human cadaver for cultural reasons. "She arrived in October in an immersion tank and looks just like a cadaver," Harmon says. "The company representative flew up and the vice president [of SKC] held an honoring ceremony and smudged the lab room where she will be to honor all of the learning that will take place with her and in the room."

The curriculum weaves Native and mainstream knowledge from the beginning. Prior to the pandemic, elders came into the classroom to role play being patients. "We teach active listening and therapeutic communication…to ask leading questions to get the patient to share their concerns," Harmon says. She also brings other cultures into the curriculum. "One of the best things we can bring to higher ed is to help students look out through others' lenses…there's so much to be learned by listening to others." SKC plans to hire more instructors that reflect the student population and is working on growing its own faculty to model the institution's prestige and the importance of Native students earning an advanced degree, returning to the community, and teaching the next generation.

SKC transitioned to the four-year program with its first cohort this past academic year, and the Accreditation Consortium in Nursing required that students in the associate's degree program receive notice and not be left out of the pipeline. Students were notified, and Harmon met with them all. "We enrolled our last associate degree cohort in fall of 2020, and they will graduate in 2022," she explains. "Students who enrolled then can enroll in the four-year program, helping them finish their RN to BSN completion program."

Planning for the transition process has taken three years, including the approval process and creation of curriculum. A lot of factors had to be considered, like transitioning the program in such a way that faculty could keep their jobs and that students would have enough clinical sites. "We had to retire the Associate of Science in Nursing and implement the BSN [degree] in a step-wise process," says Harmon. Each state has criteria about how many students can go to a clinical site with an instructor. She notes that SKC tries to keep the number around seven, since patients in the hospital are very ill. She also says the college relies heavily on community hospitals. "If there is a university with a university hospital, that hospital has to take their university students… but we don't have a university hospital…so we fight for clinical spots," Harmon says. Furthermore, students travel 60 miles or more, one way, to hospitals in Kalispell or Missoula to get clinical experience one day a week. "Students are there for 12 hours. It's a long day… but we don't want them to drive more than that one time per week."


From the time he was a little boy, Austin Taylor knew he wanted to work in healthcare. Like many children, he remembers playing doctor. But watching his younger brother battle cancer was what cemented his desire to be a healer.

"I was four or five when little brother was born. When he was one, he had brain cancer, and he was in and out of hospital. I lived with my grandparents that year. I think that's what set me down the right path," Taylor says. "My grandma is so strong, and she was the one who drove us [to the hospital]. Community members in the valley donated so we could get there." He remembers how dedicated his family was to his brother's care. "My mom stayed with my brother for nine months and never left his side, except for an occasional coffee break. Eventually he was cleared, but after a check-up the cancer had spread to his spinal cord." After Taylor's mother returned home, she entered the SKC nursing program and graduated in 2010. Today she teaches at SKC, where she is a clinical coordinator for the nursing program, accompanying students in their travels to regional hospitals.

A full plate of high school activities gave Taylor the skills to juggle work as a certified nursing assistant (CNA) and attend college. He was on the student council, a member of the tech/science club, and a lettered tri-sport athlete. He managed the basketball team, played baseball for a year, and played first trombone in the jazz band for three years.

High school also gave him exposure to the healthcare fields. He was a member of Students Together Against Negative Decisions, a group that helped students avoid drugs, alcohol, and sexually transmitted diseases by sharing information and speaking about health topics with other students. He also participated in the Hopa Mountain program, allowing him to visit college campuses and large research hospitals and labs in Washington, DC, where he saw firsthand how laboratory testing is conducted. A highlight of his trip was seeing historical medical texts that are 600-700 years old. Taylor explains that his high school experiences gave him a path to college. Initially he attended Montana State University in Bozeman and wanted to be a doctor, but that changed. "I noticed nurses are with patients a lot more. I think the time with the patient carries so much more importance, and I also like that there are so many paths you can take as a nurse: emergency nurse, flight nurse, public health nurse, and nurse anesthetist (CRNA)," he says. "The CRNA program is a doctoral program—you perform the same duties but can't work in big surgical institutions on brain surgeries. I am interested in becoming a CRNA because I like more patient contact."

SKC's nursing program employs a cohort model, offering a low student-teacher ratio and hands-on experience.

Taylor must first earn his bachelor's degree in nursing. He chose SKC partly because the incorporation of traditional knowledge is an important part of the healing process. "It's really important for Native Americans to be in the healthcare profession because there's such a shortage of them in this field, and it's important culturally. Native nurses understand the culture of other Native people more than people that have never lived on the reservation before."

While he attends college, Taylor is continuing his work as a CNA at St. Luke's Hospital in Ronan, Montana, where he started working after his junior year in high school. "I enjoy the work, and it's definitely important to have people who have worked on the reservation and know the culture. Native people respond to me differently. I understand how Native people do in the hospital as opposed to other patients."

Some students might struggle with working 13-hour night shifts full-time and going to college. Taylor concedes it is hard but that he loves it. "I work six out of seven nights in a row and have a week off at a time…I like working because I learn so much from the hospital. I am now qualified to be a phlebotomist, I am training in the emergency room to do registration, and I can take EKGs," he explains. He has also learned a lot about patient interaction. "I help them to the bathroom, bring them food, and more. I've had patients that were three days old to 104 [years]. It's really good to be able to communicate with people of all ages. Since it is such a small hospital, we are able to see all different types of patients— we are not focused on one specialty."

This breadth of experience Taylor has gained is invaluable. Moreover, he has worked in a variety of units from surgery to COVID. "I actually enjoyed working in the COVID unit," he notes. "It's hard work in that you have to gown and de-gown before going into the room, but I am learning a lot about the respiratory system."

For cultural reasons, SKC students learn human anatomy using a state-of-the-art artificial cadaver.

Michelle La Roque (Turtle Mountain Chippewa), one of Taylor's classmates in the cohort, also dreamed of being a nurse from the time she was young. And although she is not a traditional college student, La Roque proves that you can achieve your dream at any age. A trauma survivor, she dreamt of being a doctor.

In 1992, she enrolled in college but dropped out due to marital abuse. She found her way back to SKC a year ago and majored in social work. But when La Roque heard about the new four-year nursing degree program, she contacted Dr. Harmon. "She said she would love to have me," La Roque recalls. "I went through the admissions process, took the nursing exam, and passed with flying colors."

Now, with her first quarter under her belt, she is beginning her second. "To be one of the first students in this class is an honor and a privilege," La Roque says. "I have overcome many obstacles in my life to get here. I think anyone who has gone through something needs to know: Don't give up on your dream, keep going, fight for what you want."

La Roque acknowledges that it isn't always easy and there are times she cannot believe she has made it. "To be so proud and to have come this far makes me want it more," she says. "It has taken me a long time to get here, a really long time…My heart is filled with joy that through all of the obstacles and trauma, and even with surgeries, I am here in nursing. It's absolutely amazing and shocking to me."

La Roque is quick to credit SKC and her mentor. "Dr. Harmon has taken me under her wing, making my dreams come true, with my hard work and lots of study, of course. Dr. Harmon has believed in me and has helped me bloom in the field that I love."

La Roque's goal is to become a nurse practitioner. She is one of the students applying for the IHS scholarship, which requires recipients to work in Native communities after graduation. "I'd like to give back in some way, especially in my own heritage, being a Native American," she notes. She adds that her history as a trauma survivor has given her the ability to recognize the struggles that patients go through. After graduating and passing her national nursing exam, La Roque will work for a year or two getting experience in the field before enrolling in school for an additional year and a half or two years to qualify to work as a nurse practitioner. In addition to appreciating the cultural component of the curriculum, La Roque gives credit to her tribal college. "SKC is always upping their game. They started as a two-year school and now they have four-year programs and the BSN straight through. They are always trying to grow with the times," she says. Such is her respect for SKC that she would like to return later in her career as an instructor to teach future nurses.

La Roque is ready for the challenge of entering the field during and after COVID. "Yes, doctors are important, but they rely on us nurses. We are the key. We are on the front line of educating patients and using a holistic approach to treat the mind, body, soul, and spirit . . . especially with the isolation of COVID," she maintains. "You've got to be there emotionally for patients and help them emotionally to get through this. It's a difficult time for all of us, but we will get through it."

At SKC, students can earn a four-year BSN degree right at home, in their own tribal community.

Stephanie Robinson (Salish-Kootenai descendant), is one of La Roque and Taylor's classmates in SKC's first registered nursing cohort who is also working full-time at a hospital while going to nursing school. And like La Roque and Taylor, her path to nursing school was a long-held dream. She grew up on the Flathead Indian Reservation, where her father is a Salish-Kootenai tribal member. Robinson earned a bachelor's degree from the University of Montana in psychology and women's and gender studies before deciding to pursue a four-year nursing degree—something she wanted to study since high school. Although she was accepted to Montana State University in Bozeman in pre-nursing, Robinson decided not to go because it was too far away from her family.

"Nursing was always something I had wanted to do," she explains. When searching for a nursing school she looked to her tribal college. "SKC appealed to me because it is in my home community. Being on the reservation was important to me and I hope to work here." Robinson says she did not apply to other nursing programs because SKC had so much to offer. "I had heard from other nurses I work with at [St. Patrick's Hospital] that SKC was the best school in the state. The nurses that went to SKC have good bedside manner, the instructors are amazing, the nurses graduate with the best clinical experience. At SKC the student-teacher ratio is smaller, and I would get more hands-on attention," she says. "Because I am a descendant the cost was affordable, and my family wanted to move up here."

Robinson plans to devote her career to infusing Native culture in healing her community. "I think there is so much trauma that Native people have passed down from generation to generation," she explains. "I am looking forward to getting back to the roots of traditional medicine, food as medicine, lifestyle medicine, and the diet we had. gut microbiomes decrease with the more Western diet you eat." She wants to be a part of the movement to encourage people on reservations to eat more vegetables and whole grains, and to talk more openly about addiction, all the while weaving traditional Native healing into Western healthcare.

Robinson is getting hands-on experience as a nursing assistant at St. Patrick's Hospital in Missoula in the surgery department, where she works full-time while also being a mom. "It's been an adjustment for sure, still working full-time and studying. The pandemic has allowed that because classes were moved online and my husband now works at home," she says.

Her advice to other Natives who want to work in nursing? "If you want to be a nurse, stick with it, it does pay off in the long run." After graduation, Robinson hopes to continue her education to become a nurse practitioner so she can work in a small clinic. She wants to advise patients in her community about traditional diet and lifestyle to overcome high cholesterol, high blood pressure, and diabetes. By marrying her tribe's traditional diet with Western medicine, she can help patients reverse these conditions, wean them off medications that can cause harmful side effects, and increase their quality of life.

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SKC's first registered nursing cohort is experiencing "trial by fire," with the pressures that the pandemic has brought to bear on their community and their own families. However, this first group of students is as dedicated to their dream as they were when the first flame of interest in a healing career was ignited in them. They will carry that commitment forward to their communities, lighting the way to better health for their people.

Salish Kootenai College
The mission of Salish Kootenai College is to provide quality post-secondary educational opportunities and support for Native Americans, locally and from throughout the United States, to achieve their academic and career goals. The College will perpetuate the cultures of the Selis, Ksanka, and Qlispe’ peoples. The College will impact its community through service and research.

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Dina Horwedel, JD, is the director of public education at the American Indian College Fund.

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