AUTHORS
Barbara Overman PhD, Clinical Associate Professor
Linda Petri MA, Project Manager
Ursula Knoki-Wilson MSN, Chief Clinical Consultant for Advanced Practice Nursing for IHS
AFFILIATIONS
1 University of New Mexico College of Nursing, Albuquerque, NM, USA
2 University of New Mexico, Albuquerque, NM, USA
3 Indian Health Service, Chinle Comprehensive Health Care Facility, Chinle, AZ, USA
PUBLISHED
May 1, 2007
Abstract
Introduction: This study explores the experiences of individuals working within the healthcare system in Arizona and New Mexico Indian Country. The aim was to understand their interests and needs related to health career advancement, identify support mechanisms, and determine barriers to progress.
Methods: A community action research approach was employed, utilizing semi-structured interviews as part of a two-part survey. Participants were health workers in Arizona and New Mexico Indian Country who expressed interest in career advancement through workplace questionnaires. Interviewees were selected to represent diverse occupational backgrounds, work sites, ages, and cultural identities. Investigators independently recorded notes during interviews, subsequently reviewing and agreeing upon responses, which were then digitally transcribed. QRS Nudist software (QRS Software; Melbourne, VIC, Australia) was used to thematically analyze interview responses using a constant comparative method.
Results: Twenty-five interviews were conducted in community settings convenient for participants between February and April 2003, lasting 30 to 60 minutes. Eighty percent of participants were American Indian, and 80% were women. Key themes regarding barriers included financial constraints (“making ends meet”), navigating the educational system, workplace uncertainty and inflexibility, and concerns about negatively impacting children through career decisions. Participant-identified needs centered on financial stability (“making sure the bills are paid”), ensuring children’s well-being, and confirming the value of further education in the workplace. Cross-interview themes revealed sequential, incremental educational steps, frequent interruptions and setbacks in pursuing education, and reliance on informal, verbal information networks for career guidance.
Conclusion: Multiple barriers impede career advancement and education for health workers in Indian Country. Supporting their progress requires collaborative partnerships across education, health services, and community sectors. Essential supports include financial management resources, workplace policies that encourage career-oriented education, clear and consistent information about educational processes, and improved course accessibility. Health professions schools should recognize community-based graduates as valuable ambassadors, providing ongoing, accurate information. Innovative programs addressing loan consolidation and financial management are crucial. Interdisciplinary collaboration within education to streamline prerequisite coursework is also recommended.
Keywords: American Indians in health professions, career mobility, community-based health workers, minority groups/education, Navajo health professionals, research/manpower, rural health manpower.
Introduction
The region known as ‘Arizona and New Mexico Indian Country’ is a vast, rural area encompassing parts of four western US states. Notably, it includes portions of the Navajo Nation, home to 180,000 people within a 27,000 square mile area (Fig 1) and the largest federally recognized American Indian tribe[1]. This unique region is characterized by specific cultural, healthcare delivery, and socioeconomic factors. The majority of residents are American Indian, often speaking a language other than English at home [1, 2]. Healthcare services are primarily delivered by the Indian Health Service (IHS), a federal system within the US Public Health Service. Like many rural areas, maintaining a stable and adequate health workforce is challenging. A significant portion of the health workforce comes from outside the community on short-term assignments, with many professionals lacking cultural alignment with the community.
Figure 1: The US region known as ‘Arizona and New Mexico Indian Country’.
The composition and stability of the health workforce are critical issues as these communities move towards greater local management and control. Historically, IHS has relied on predominantly non-native, western medicine professionals. While IHS contributions to public health, particularly in communicable diseases, are significant [3], contemporary health challenges, including chronic disease disparities and behavioral health needs, are best addressed by community members with deep cultural understanding and community trust. Native healthcare professionals, who are more likely to establish long-term community roots, can bridge traditional and western healthcare perspectives, enhancing communication and patient care. As Navajoland moves towards self-governance in healthcare, native leaders in health are crucial to integrate cultural and community values into the evolving system.
Although professional roles have been largely filled by outsiders through IHS, local residents have been vital in ancillary and technical positions. These residents, serving as aides, technicians, and practical nurses, provide essential cultural interface within the healthcare system. This group represents a unique and valuable resource, possessing both community knowledge and healthcare system experience. This study focused on understanding the experiences of these health workers within the system, exploring their aspirations, interests, and needs concerning career advancement. The study aimed to pinpoint supportive measures and identify obstacles hindering their professional growth.
Methods
Community action research methodology was chosen to understand the challenges faced by residents of Arizona and New Mexico Indian Country in pursuing career advancement. The study employed a two-part survey design, incorporating both written questionnaires and qualitative interviews. This report focuses on the qualitative interview component.
The study protocol underwent review and approval by the Navajo Health Research Review Board (NHRRB), Navajo and Albuquerque Area Indian Health Service Institutional Review Board, and the University of New Mexico Institutional Review Board. NHRRB ensures community stakeholder involvement in research concerning the Navajo Nation, from approval to dissemination. Prior to NHRRB review, the study was presented to and endorsed by four health facility councils and five local chapter houses. NHRRB also modified survey items before granting approval.
Local dissemination of findings to relevant tribal committees is mandated by the NHRRB. Following NHRRB guidelines, study results were presented to the President of the Navajo Nation and three other tribal education and health services committees. The NHRRB actively promotes community engagement and service through research application. This community engagement model [4] aligns with and strengthens the community action research methodology by providing platforms for validation and community input.
Sample selection
Interview participants were selected from 245 health workers across Arizona and New Mexico Indian Country who responded to workplace-distributed questionnaires about career interests and needs (workplace locations shown in Fig 2). The questionnaire included an option for participants to indicate their willingness to be contacted for an interview. A 10% purposive proportional sample of questionnaire respondents was chosen to reflect the occupational background, work site, age, and cultural identity distribution of the overall respondent group. Of questionnaire respondents, 77% were American Indian, 80% were over 31 years old, and 62% worked in highly rural settings. Approximately one-third were nurses, one-third were community health or community health education workers, and one-third were clinical technical support personnel at the time of the survey. Consenting and selected individuals were contacted by phone or email and invited for in-person interviews with the investigators. Interviews were scheduled at the participant’s convenience, within their home or work communities.
Figure 2: Workplace locations.
Data collection
Interviews were conducted jointly by two investigators (BO and LP) using a semi-structured questionnaire with six open-ended and two closed-ended questions (Appendix I). The questionnaire was designed to encourage interviewees to share their experiences related to pursuing further education for health career advancement. Questions focused on eliciting views on barriers and facilitating factors encountered when considering or attempting career advancement and educational steps. No pre-defined options or suggestions from previous research were introduced; the questions were designed to be open and exploratory regarding barriers and facilitators. Both investigators independently took handwritten notes during interviews. Immediately following each interview, the investigators reviewed their notes together to reach agreement on content. A single, agreed-upon set of notes was then transcribed into a word processing program within three hours of the interview.
Data analysis
QRS Nudist software (QRS Software; Melbourne, VIC, Australia) was used to organize interview responses by question, compiling all responses to each question sequentially. Interview data were analyzed using a constant comparative method to identify recurring themes within responses. Themes were identified both within responses to each question and across all questions through extensive and iterative reviews of the text, initially done individually and subsequently jointly by two investigators. Emerging themes were further reviewed, discussed, and refined in collaboration with the third investigator.
Results
Twenty-five personal interviews were conducted between February and April 2003. Thirty-seven individuals were initially invited; six declined due to time constraints, and six did not attend scheduled interviews. Table 1 summarizes the occupational and demographic characteristics of interviewees. Interview durations ranged from 30 to 60 minutes. Findings are presented in two categories: (i) themes recurring within individual interviewees’ stories; and (ii) notable patterns observed across interviews from the interviewers’ perspective.
Table 1: Characteristics of interviewees (n = 25)
Themes within interviewees’ stories
Key barriers emerging from interviewees’ narratives included financial constraints, challenges with the educational system, and workplace uncertainty and inflexibility. Factors crucial for enabling progress centered on ensuring children’s well-being, and confirming the professional value of further education. These themes are elaborated below.
Financial barriers: The most prevalent barrier was ‘making ends meet.’ Financial and time pressures created a cyclical barrier to career progression. Limited local educational programs coupled with the costs and time commitment of attending programs were significant burdens for already financially stretched workers with demanding schedules. A majority of interviewees were the primary financial providers for their families, including single parents or providers for extended family members.
Maintaining full-time income was essential, intensifying time pressures. Commuting costs, including fuel and vehicle maintenance, added to the financial strain. Programs located far away or requiring full-time study presented the choice of family relocation or maintaining a second residence for student use, involving intermittent commuting.
Housing costs, often underestimated initially, became a breaking point for some who had attempted further education. Unanticipated housing and related expenses contributed to program withdrawal and study discontinuation. Housing costs may be less on reservations, especially when living within family homesteads, where rent or mortgage payments may be absent.
As interviews progressed, it became clear that financial concerns extended beyond personal bills to include the management of current obligations while taking on new educational commitments. Many interviewees mentioned supporting children’s education in private or off-reservation schools, perceived as superior to reservation schools, adding to their financial responsibilities.
Scholarship applications were viewed as cumbersome and unlikely to succeed. The common perception was that limited scholarships were reserved for exceptional academic achievers or influenced by political factors within Navajo Nation and IHS scholarship programs. The real financial burden of education for these students encompassed tuition and fees, plus travel, housing, and potential relocation costs, on top of existing debts and bills.
Dealing with the educational system: A second set of barriers related to navigating the educational system itself. Complex paperwork, requirements for online applications, misinformation, delayed information, and excessive ‘red tape’ characterized their experiences in initiating career advancement. One health worker succinctly stated that ‘misinformation resulting in cost and delay’ was the most significant barrier.
Prerequisites for health professions courses and in-class experiences posed obstacles. Misinformation led to taking unnecessary courses, and changing prerequisite requirements created confusion and sometimes necessitated additional coursework beyond initial plans. Prerequisites were reported as infrequently available, scheduled at inconvenient times for working individuals, and often full. Interviewees described prerequisites as ‘dreadful,’ ‘difficult,’ and ‘irrelevant.’
Difficulty accessing academic support during courses was common. One instance involved a single tutor for all math and science courses at an institution, offering only one weekly tutoring session. Despite traveling over two hours for a session, an interviewee was unable to get her questions answered, leading to course withdrawal and study discontinuation. Contacting faculty was also challenging. One student traveled to campus, only to find the faculty member absent from their office.
Uncertainty and inflexibility in work situations: Inability to accommodate school schedules was frequently cited as an obstacle to advancement. Difficulty obtaining clear information about the implications and feasibility of reducing work hours while pursuing education was common. Job and benefit (including health insurance) retention remained unclear. Securing a job in their home community post-education was desired, but lack of assurance acted as a barrier.
Making the decision: ‘Making the decision’ emerged as a key theme related to factors needed for respondents to advance their careers. Participants expressed determination that once a firm decision was made, progress would follow. Despite barriers, the act of committing to a personal path was seen as the catalyst for advancement. This determination was linked to an underlying belief that maintaining focus on motivating factors would sustain them on their chosen path.
Knowing that children would not be disadvantaged: Several themes surrounding reducing uncertainty to facilitate ‘making the decision’ emerged. A strong consideration was ensuring that children would not be negatively impacted by a mother’s career advancement choices. Potential disadvantages for children were perceived in both scenarios: pursuing education and career advancement, and not pursuing it.
Mothers sometimes resorted to leaving families for extended periods, returning home intermittently during necessary education; several interviewees had prior experience with this. The personal cost of missing daily family life and children’s activities weighed heavily, particularly for those with past experiences.
Considering options for children’s care within the community or relocating children while pursuing education was a constant part of the decision-making process. Furthermore, ensuring that funds spent on a mother’s education would not detract from children’s education or developmental opportunities was interwoven into discussions of ‘what would help’. One woman stated that ‘knowing that my kids are not suffering because I’m going to do this’ would be a key support.
Conversely, the potential for improved future opportunities and resources for children if a parent returned to school was an underlying motivator. Some interviewees mentioned their pursuit of education and career advancement as a positive example for their children.
Being sure of the worth of education in the workplace: Respondents indicated that confidence in the workplace benefits of further education would facilitate their decision to pursue career advancement. ‘Worth’ encompassed acquiring necessary knowledge for licensure exams and securing employment. Obtaining a job in their home community after graduation and assurance that education would translate to career advancement and higher earnings were important considerations.
Patterns of progress as seen from the outside interviewers’ perspectives
Baby steps on the path: A pattern of incremental educational and career ‘steps’ toward a health professional career goal emerged. For example, aspiring nurses might first become nurse’s aides, then medical assistants, planning eventually to become practical and then registered nurses, rather than directly enrolling in a registered nurse program. Some interviewees were considering ‘lateral’ degrees (e.g., a second associate’s degree). Each small step required time, travel, complex family logistics, and sacrifice. The need to climb a ‘baby-step career ladder’ (as termed by investigators) appeared to be a common assumption.
Interruptions and failed attempts: Health workers experienced frequent setbacks, false starts, and derailments. Respondents reported taking incorrect prerequisites, enrolling in courses only to be deemed ineligible mid-course, or accumulating courses that ultimately did not contribute to their goals. Some even found themselves ineligible for financial aid due to excessive credits. Missteps occurred even among those with continuous educational engagement.
Interruptions and ‘failed attempts’ were frequent, arising from both personal life events and academic system issues. These interconnected when life events hindered meeting academic expectations. Interviewees reported a seemingly high incidence of accidents and health crises affecting themselves or family members, disrupting studies. This reflects the reality of higher accident and illness rates in this rural, culturally unique region. Such events sometimes led to relocation (back to the reservation) for personal or family support, such as caring for an ill parent.
Confusing and intimidating learning environments were a common experience. One interviewee ‘just left’ a large course due to incomprehension and lack of support. Many withdrew from prerequisites perceiving them as irrelevant. Most courses were designed for adolescent students and perceived as insensitive to adult learners’ needs.
Information-gathering patterns: Nearly all narratives included stories of information gathering for career advancement, primarily relying on informal, word-of-mouth networks within the community and workplace. Current or former students within these networks were frequent sources. Formal workplace networks and supervisors were mentioned as information sources in only two interviews. Higher education advisors were consulted mainly for problem-solving after false starts, conflicting information, or problems arose. Information from informal sources was often unverified, leading to actions based on potentially outdated or inaccurate information.
Discussion
The study revealed an interconnected set of barriers for predominantly native health workers striving for health careers while remaining in their rural communities. The perspectives shared are often unheard by higher education institutions and health workforce policy analysts addressing health professional shortages, workforce diversity, cultural competence, and rural health workforce stability. Literature reviews found no directly comparable studies.
In-place, culturally and linguistically embedded health workers are a valuable resource for addressing workforce deficits, particularly in native communities in the USA. These professionals bridge western and native health practices, facilitating effective health communication and shaping future healthcare in these vulnerable communities [5]. Their experiences can inform community-focused health workforce development but require collaboration across sectors not typically aligned.
Through NHRRB requirements for approval and dissemination, these health workers’ voices have reached diverse audiences. Institutional and tribal advisory boards have reviewed findings, and the study was presented to the President of the Navajo Nation. Community boards consistently express a desire for these health career opportunities for their youth and recognize the value of practitioners sharing native culture with patients.
Influences on how people pursue career paths
Interviewees appeared to operate under a career path model of sequential technical roles leading to professional health careers. This approach involves extensive training hours and years with limited gains in responsibility, authority, or economic reward. The multi-layered, stepwise federal employment system for many health workers may contribute to this perception. While career ladders and ‘articulation’ between nursing levels are increasingly discussed in health professions education, the ladder remains long and fragmented between technical and professional ranks. The disconnect between education and service institutions in the USA may exacerbate this issue.
Frequent interruptions due to family health crises and accidents, delaying career plans, reflect the background population health disparities. American Indians in Arizona are significantly more likely to die from diabetes, accidental injuries, and homicide compared to all Arizona residents [6]. Extended Navajo family obligations necessitate presence and participation during such events. Navajo culture is event-driven, not time-driven, prioritizing presence until an event is resolved, contrasting with the time-bound scheduling of health professions education programs.
While ‘why’ questions were not directly asked, several factors likely contribute to common career pathways:
- Accessibility and affordability of local options.
- Potential counseling of native students towards technical post-secondary pathways.
- Inadequate preparation in local secondary schools for professional-level education.
- Historical market opportunities through IHS primarily in labor and technical roles.
The disconnect in providing, finding, and using information
Reliance on word-of-mouth information networks is unsurprising in a cultural group valuing oral tradition. Written information is not inherently more valuable than the word of a respected person.
Educational institutions often rely on workplace-based health educators or counselors for information dissemination. However, widespread misinformation and false starts suggest that information accessed and used is often outdated. Relationships based on clan affiliation and guidance from native individuals who have progressed in health careers are more influential than workplace roles and written materials. Workplace sources may be avoided due to fear of job loss or reduced hours upon revealing educational aspirations.
Disseminating accurate information through community networks and providing accessible, helpful resources is crucial. Current and former students should be seen as community ambassadors for education programs and provided with up-to-date program information.
What they said they needed
Salaries and benefits: Ensuring adequate salaries, benefits, and local job and course availability is crucial for native individuals to manage finances while pursuing education. A clear link between educational advancement, responsibility, and salary is needed in the workplace. The Navajo Nation Division of Economic Development reports low per capita income, high unemployment, and a significant percentage below the US poverty level in these communities [1]. Many do not work in the dominant economy, and earnings often support extended family and clan members. Disrupting income for these health workers makes entire family units vulnerable. From a community development perspective, maintaining income flow is essential. To prevent ‘brain drain’ and economic underdevelopment from residents leaving for education in urban areas, local education and job opportunities are vital.
Needing to be sure bills are paid: Participants often carry significant debt loads for vehicles and other expenses. High cost of borrowing is likely due to residents’ economic backgrounds. Property ownership is not structured in the same way as in dominant US culture, potentially hindering credit access. Once debt is established, individuals are bound by it. Programs assisting with loan consolidation, deferment, and lower interest rates would greatly benefit residents and enhance their career advancement opportunities.
Needing to be sure that children are not disadvantaged by the mother’s decision to continue education: Local courses, reducing education costs and time, would alleviate concerns about children being disadvantaged by a mother’s educational pursuits. Economic supports minimizing financial strain on families would also help. Local job opportunities would allow children to remain near extended family and within their community.
Conclusions
Supporting career advancement for health workers in Indian Country requires prioritizing partnerships across education, health services, and community sectors to reduce barriers and enhance support. A stable, culturally competent health workforce can significantly improve both health and economic conditions within native populations.
Interdisciplinary collaboration within education to streamline prerequisite courses is essential for reducing the ‘hassle factor’ for rural students. Expanding course access in rural areas can reduce time burdens, but accessible tutorial support and teacher interaction must be included. Institutional interactions with students should be personalized, problem-solving oriented, and culturally sensitive. Procedures and prerequisites should facilitate, not impede, progress.
Clear, published policies on salary support, benefits, and tuition reimbursement for employees pursuing education should be standard in health sector workplaces. The Navajo Nation should consider legislation ensuring benefit maintenance for students. Personnel policies prioritizing local resident hiring in local institutions would be beneficial.
Loan consolidation and deferment programs for native students in health career pathways are crucial financial steps. Enhanced communication and collaboration between education and service sector leadership to support students are also needed.
Based on these research findings, the nursing community, in collaboration with University of New Mexico faculty and staff, has developed a program to support nursing career advancement. A Navajo nurse mentorship project has been created to empower Navajo nurses as resources and mentors, providing them with current information on local health professions education programs. A new organization fostering Navajoland nursing and collaborations with education, research, and service organizations has emerged, promoting cultural pride and commitment to Navajo career advancement in nursing.
Acknowledgement
This project was supported by a grant from the Robert Wood Johnson Partnerships for Training Project.
References
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