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 programand 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 carestarting 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."
SKC'S PROGRAM AND CURRICULUM
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
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
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
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
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
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
programyou 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
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
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
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
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 degreesomething 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
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.
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.
Dina Horwedel, JD, is the director of public education at the
American Indian College Fund.