Last Day in Cherokee

    I can honestly say that I have never been in such a welcoming or generous clinical environment. I’ve had some wonderful nurses through clinical at Methodist, but I received warmth not only from the nurses, but the entire treatment team. From the moment we stepped on the floor, we were invited to ask questions to the entire treatment team. Physicians and nurses sought us out to give us excellent clinical opportunities. Our contact staff, Kayla and Victoria, took time outside of their work days to meet with us to teach us about the Cherokee culture and the wider population of Swain county and Jackson. Through our experience at the Museum with Jerry Wolfe, to our time in the Village, so many people have taken the time to teach us about their culture. On our last clinical day, as a surprise, we were taken to Kituwa. The staff shared that Kituwa is the place the Cherokee believe they were first placed upon the earth. I am honored that they shared this special place with our group. Victoria also gave our clinical group the beautiful gift of a hand-beaded lanyard.

            Our role this week was observation, but we did get the opportunity to contribute by collecting clothing and donations for children in the foster care system and hospital in general. Victoria informed us that when children come into the emergency room, it is so important for them to have a security item, something for them to hold onto for their mental and emotional health. Because of generous donations from those at Methodist college, churches, and families we get to help support the work Cherokee is doing to support the health of these children.

            One way I think this culture will continue to get healthier is by being in control of their own healthcare. Victoria shared with us that Native American healthcare was run by the U.S. government, but it is now in control of the Cherokee. The community here knows their health problems, and how to address them in a way that aligns with their cultural beliefs. The Cherokee have also implemented programs to maintain their cultural heritage such as teaching their language and culture’s history to their children in schools. Resources in the community such as the Museum, Village, Unto These Hill’s production, and festivals are some of the ways I saw them teaching about their culture. When we visited the Village, many of the staff preforming traditional dances were young-adults. I thought it was great that a younger generation was involved. It is important that the Cherokee are able to pass their heritage on to the next generation because for so long, there were not allowed to speak their language or practice their cultures in the boarding schools.

            Something I did this week out of my comfort zone was attend a Healing Touch class led by a nurse at the hospital. This is something I would not have considered trying. I am glad that I was exposed to this practice. It is something I had heard that nurses could be certified in before, and it is a complementary therapy nurses may utilize in different healthcare settings. While here, I also went white water rafting, which I never thought I would try. I’m glad I had such a fun and supportive group through all of this week’s experiences.

            Something that impacted me this week was observing the interdisciplinary teamwork at Cherokee. I have never seen staff work together in such a respectful manner. I loved the interdisciplinary rounding and would like to see this implemented in more hospital systems at home. I also enjoyed seeing the NUKA model of care implemented. Cherokee does a good job at looking at a person holistically: mental, emotional, physical, and spiritual. This week, the following example was given: Rather than just focusing on tertiary health promotion, such as treating the symptoms of type 2 diabetes and education on how to manage their condition, look at the mental side. What stressors are in their life? What unhealthy coping mechanisms are in place that could have led to the development of this condition? Start by addressing the mental health, and the physical health management is more likely to follow.

            This is the best course I have ever taken. I have learned so much about the dynamics of how an individual’s culture affects who they are as a person and how it impacts their care. I also have grown in my pediatric assessment skills and feel more confident and equipped to recognize and respond to pediatric emergencies. This was a wonderful course.

             Most of all, I believe that the model of care being done at Cherokee Indian Hospital represent the best ideals of nursing, and healthcare overall. I am so thankful to the staff at Cherokee for their generosity, openness, desire to teach, and for making us feel like family. Thank you!

Mission Children's Hospital

       Greetings! Today our group toured the Mission Hospital in Ashville, North Carolina. We got the opportunity to see their pediatric unit, pediatric intensive care unit (PICU), and their newborn intensive care unit (NICU). We were not able to go into the pediatric oncology unit, but it was a unit present as well. We also went to an outpatient center that had a wide variety of pediatric specialist in one central location. During my clinical rotation in pediatrics, I never had a day on Methodist’s pediatric floor due to low volume of patients, so this was my first clinical experience in a pediatric unit (excluding the nursery). I was impressed with Mission’s hospitals units. What was really interesting to me was the focus of care. One of the nurses shared that she isn’t just caring for the child, but the immediate family, but also the extended such as grandparents. This is a focus of care that I’ve learned about in pediatrics lecture, so it was helpful to see it in the practice setting. Another thing that stood out today was just how the hospital was structured. There were specific treatment rooms that children were taken into anytime there was going to be an unpleasant or frightening procedure (ex. Foley catheter insertion, IV sticks, ect.). Our tour nurse shared that the idea behind this was that children would associate their own rooms as safe place. This also applied to the children’s play rooms, where nurses are not allowed to even give medicine to the children while they’re in them. Because hospitalization throws off a child’s routine and can be stressful, I think these pushes to give children a safe space is a great idea. Another impressive part was that the nurses were doing a pilot study where they wore a “medication sash’ while passing medications, so other nurses or care providers knew not to interrupt them. The nurse shared that the idea behind this was to reduce medication errors and help nurses focus.

            A child’s hospitalization can be incredibly stressful on a family. There are many dynamics to this disruption, such as family support system, ability to take off work, child care for other siblings, and socioeconomic income. There is also the possibility of commute time. On our tour, our nurse discussed a couple different way that this organization is trying to apply family-centered care. One of those ways was doing interdisciplinary rounding for patients, and including the parent in these rounding’s. The nurse explained that this keeps the parent in the loop and enables the parent to ask questions or correct the care providers if misinformation is given. This environment of interdisciplinary rounding on patients was similar to what Cherokee Indian Hospital does for their rounding report on inpatients. This was a practice in both Cherokee and Mission hospitals that I would like to see applied more at hospitals at home. The patient’s rooms have a pull out bed so family members can stay with the child. The nurse reported that one meal is provided for a family member at every meal. Housing can also be provided for families at other rooms in the hospital. The nurse reported that housing is also available to families for a set number of days at a resident similar to the Ronald McDonald houses, so that caregivers can be within thirty-minutes of their children. Something that was different from what I’ve seen in Cherokee Hospital is the amount of family members or visitors allowed for the children, which only two visitors at a time. The nurse said exceptions to this case may be in palliative situations. In previous clinical days at Cherokee, we have learned that family is important to this culture, and hospital rooms are constructed to allow for large family or community groups to visit.

            My favorite part of the day was visiting the hospitals NICU. We were able to see a variety of patients, and the nurse discussed the issue of becoming attached to these patients, and needing to take care of themselves emotionally and mentally. The nurse stressed the importance of using her resources. She said that she frequently finds support through debriefing with the hospital Chaplin. It’s important for nurses to take care of themselves so that they do not become burnt-out or hard-hearted. In working in any unit this is important, and something we as new nurse may need to utilize. I had a great day!

            Following our tour in Ashville Mission Hospital, we stopped by the Biltmore Estate. The home and grounds were beautiful. It was fun to learn more about the area, and a good bonding experience for our clinical group. Tomorrow we have clinical at Cherokee Indian Hospital. We will also be going through donation’s tonight as part of our service project. Looking forward to tomorrow!

                                         A photo I snapped of the Biltmore today. It was beautiful.

Visiting the Cherokee Village

Today our group visited the Oconaluftee Indian Village. This village was built to represent a Cherokee village as it would look in the 1700’s (Cherokee North Carolina, n.d.). Individuals there demonstrated traditional crafts and skills that the Cherokee would have done at this time. Examples of various crafts we observed were: pottery making, beading, jewelry making, weaving of belts and blankets, basket weaving, hunting and weapon tools, traps, and instruments. We also had the opportunity to see traditional dances and a lecture on the clan political system.

            Yesterday at clinical, our group had the opportunity to speak with a social worker at Cherokee. She discussed with us the topic of historical trauma. The social worker shared that many Cherokee children were taken from their families and were sent to boarding schools that forbid them from speaking their language and cultural practices. At the Cherokee village today, they discussed that because of these restrictions, many of that generation and the following do not speak the Cherokee language. In a way, a generation was lost. Jerry Wolfe, the speaker at the Cherokee Museum we visited on Monday, speaks about his experience at a boarding school as a child, where he shares that the students were only allowed to come home for two weeks, during Christmas (Museum of the Cherokee Indian, n.d.). As a way to combat this historical trauma and preserve their culture, the Cherokee are working to instill in their children their native language and traditions. A staff member at the Cherokee village today shared that a way that they are doing this is to teach Cherokee language and alphabet to children in the school system. In addition to this, we learned earlier this week that there are schools that exclusively speak in and teach the Cherokee language. In the community, the individuals with the highest authority are the Elders. This is because, in the Cherokee culture, the elderly are highly respected. In the hospital on Tuesday, we learned that the Tribe’s counsel must approve the budget and referrals at the hospital.

            During my clinical day, many of the family structures I observed included a mother with children, who reported having a significant other. Many of the mother reported that their parents or the children’s grandparents regularly helped assist in childcare. Upon arrival to Cherokee, our contact Kayla shared the story about when a past client had gotten in an accident, not only extended family, but the neighborhood as well came out to the hospital to support this family. There are resources within the hospital setting available to these clients as well, such as the social worker that we spoke to and care coordinators. When I think of the word resilience in the sense of families and children, I think of a strong community and support network. A group that will rally around a family in need to assist and ‘pick them back up again’. I believe having that system of a close, supportive community in place is key to families overcoming challenges and coming out stronger.

            From what I observed at the performance of ‘Unto These Hills’ and the staff at the Oconaluftee, there is a sense of strong cultural pride and desire to preserve their way of life. Our contacts at Cherokee hospital and staff have been wonderful. They are passionate about the model of care that they are working to provide and about the community they serve.  I am so thankful to this community for all they have shared with us these past few days.

            Tomorrow we will visit the Children’s Mission Hospital. I am looking forward to visiting a children’s hospital because I never have. It will be an interesting experience!

References:

Cherokee North Carolina. (n.d.). Oconaluftee indian village. Retrieved from:          http://visitcherokeenc.com/play/attractions/oconaluftee-indian-village/
Museum of the Cherokee Indian. (n.d.). Jerry Wolfe-christmas at the cherokee boarding school in the 1930s. [Video file]. Retrieved from: http://www.cherokeemuseum.org/christmas-at-cherokee-boarding-school/

First Day of Clinical at Cherokee and Unto These Hills

   During this clinical day, our group had the opportunity to observe at Cherokee Indian Hospital. The healthcare system in this community is ultimately run by the tribe and its Elders. When you walk into the hospital, there is a sign that says, “It belongs to you” Throughout the day, I heard healthcare workers say that they wanted to use the tribe’s resources responsibly. In order to make referrals or programs, staff said that the Elders of the tribe must approve of it. During the start of the clinical day, we got the opportunity to observe an interdisciplinary meeting/rounding on the inpatient floor. There were nine patients total. I was blown away with the demonstration of mutual respect and clear communication during these meetings. Different healthcare workers present included: Certified nursing Assistance, nurse, nurse manager, physician, physical therapy, employee health, nutrition, social worker, and behavior health. I was so impressed by their collaboration. Client’s treated on the floor ranged from infants all the way up to clients in their nineties. The other half of the day, we observed pre-natal care visits. It was exciting to care for expecting mothers, and to the teaching provided by staff to them.

            During our post-conference debriefing session, students from other observation sights shared what they learned about planning appointments for patients who come in. They shared that when a client comes in, all appointments and referrals are made that time. They can also check to see what regular appointments or screenings are due for them, and schedule them at that time. What I found really impressive that they shared was that most clients get scheduled for an appointment within two weeks to a month.

            Similarities that I saw within the organization included a detailed report on the patients being treated, similar to nurses shift report. But what was different, was that the shift report was interdisciplinary! This was the morning report I mentioned above that included the many healthcare team members. A lot of the teaching and tests offered at the pre-natal clinic were similar to ones I’ve seen offered at clinics at home. Another difference was their integration of complementary or alternative medicine. Our Nurse Educator contact Kayla shared with us that the Cherokee use many plants and herbs found in the region to treat illness. When I asked a staff member at the hospital what herbs and plants were used, she told me that it is something that the Cherokee keep private. We also got to attend a meeting about Pain Management. A goal they shared was to offer multiple ways to treat and manage pain. In addition to doctors, nurses, physicians, social workers, and there were complementary healthcare workers. Other practitioners there included a chiropractor, acupuncturist, and massage therapist. It was encouraging to see the different disciplines working together, both the medical professionals and complementary practitioners.  

            At the end of the day, we saw the play Unto These Hills, which was an outdoor drama representing Cherokee history. It was really interesting to see this production because it helped me to piece together the Tribes history from what I saw in the museum the day before. This was especially helpful to have this base when we went to the Cherokee village Wednesday morning.  

                                       A sign at Cherokee Hospital that says, "It Belongs To You!"

Day One at Cherokee

            Today we visited Cherokee Indian Hospital for orientation. We met up with our Nurse Educator, Kayla, who gave us a tour of the hospital. Following the hospital, we went to the Cherokee Museum, and met up with Jerry Wolfe, who shared with us some Cherokee history and traditional stories about animals found in the area.  Two were about how the chipmunk got his stripes and the Opossum his ugly tail. He was also a World War II veteran. Today is the anniversary of D-day and he described his experience that day. It was incredibly humbling that this highly respected elder took the time to share with our group. 

            Cherokee hospital was built to reflect the culture and beliefs of the Cherokee community. The Cherokee value nature, which was reflected in the construction throughout the hospital. Our contact Kayla told us that when designing the hospital, the team met with tribal elders to get their input about what they wanted included as far as services offered in the hospital and design. The client’s rooms and all of the hallways in the building had large windows to view the mountains. I’ll include a photo below looking out of the window. Even in their main lobby, the floor was the pattern of a river with animal tracks and fish. There were live trees and plants inside, the beams were made to resemble trees, and traditional symbols were incorporated throughout. There was a beautiful water-spider mosaic on the floor, which linked back to a traditional Cherokee story about the origin of fire.  

            Cherokee members value family and community being near when an individual is sick or in poor health. The rooms were constructed to be big enough to have pull-out beds and adequate space for multiple family members at all times. They also have hospice rooms which have the same size room as a normal in-patient, but in addition have a door to an adjoining room just for family and friends. These include a kitchenette area as well to make the families stay comfortable. There is a small booth-like area that the nurse sits in so she can view both sides, but still give privacy. Picture included below. The hospital also offered multiple services in one location: physical therapy, in-patient, and dental are some examples. Having these areas in one central location helps increase access to care and the likelihood that client’s will follow-up. 

            Something Kayla told us that I found interesting and challenging to process is that Cherokee hospital states the right to discriminate because they are a sovereign nation. Cherokee hospital hires non-members to staff the hospital. She shared that even if you have been at the hospital longer or have more experience, a Cherokee member with less experience can be hired over you for promotion positions. Another really interesting tid-bit we learned was that Cherokee does genetic blood testing to determine the percent of Cherokee a child is in the the first few days after birth. If the individual meets the certain percent of Cherokee, they can get full benefits and treatment at the hospital and clinics for free. If they do not meet that percent, they do not qualify and are known as non-beneficiaries. 

            A big take-away today for me was that the Cherokee are proud of their culture. A frequent theme I heard throughout the day was their desire to preserve it and pass their traditions onto the next generation. Something I thought was interesting about Cherokee history was that the Eastern Band of Cherokee is actually made up of tribal members who refused to go on the Trail of Tears, and instead hid in the mountains. Later, they had to buy the land back that their tribe originally was driven off of. 

            One of the values I learned about today was that women traditionally were respected in their culture; it was a Matriarch society. Women worked the fields, choose their spouses, and owned their land. Women and Elders are highly respected and are active in leadership. Their tradition of strong women reminded me of my own family, which is made up mostly of women who are leaders. The Cherokee highly value their elders, which is reflected in their care. Our contact Kayla said that when an Elder becomes sick, family members take over care. Businesses often give the family members time off in order to care for their elders. In my culture at large, this is different. Elders are often mistreated. Our elderly are often placed in nursing homes to be cared for rather than the home by family members. Although the nursing home staff may be wonderful caregivers, their patient to staffing ratios do not always enable them to give the best possible care. When my mother can no longer live on her own, I hope that my sisters and I can care for her. I wish that my culture had this level of respect for our older adults. A value I thought was interesting was their belief in a mind-body-spirit healing. They discussed how drug and alcohol abuse is common in the area, and that it relates back to historical trauma. Kayla said that their focus of care is that they must treat the mental health issues (ex. Coping, drug abuse), before focusing solely on treating their physical health problem (ex. Diabetes). She related it back that poor coping mechanisms, such as overeating or eating unhealthy foods, can lead to developing chronic health issues of diabetes later. This was a fascinating approach. 

            A way that Cherokee try to pass their culture on to children are through teaching them their tribes history, stories, and language. Today, Kayla informed our group that there is a program that teaches Cherokee children the traditional language. Parents whose children are enrolled in this program must sign a contract agreeing only to speak the Cherokee language to the child as well. Despite the emphasis on preservation, the Cherokee are not necessary isolated. Many of the children we saw today were wearing t-shirts depicting popular children cartoon shows. Cherokee also has many shops and attractions for tourists. A big portion of the tribe’s revenue came from the Casino. I spoke to three different tourists who said they planned on visiting the casino. The boundary is located near the larger city of Asheville as well, so the children are exposed to the broader United States culture. 

            My favorite part of the day was getting the opportunity to learn more about the Cherokee culture through stories by Jerry Wolfe and the Cherokee Museum. Tomorrow is our first observation day at the Cherokee hospital. Check out some photos below!

 This image is of the Cherokee hospital. Nature was represented throughout.

 Here is an image of the scene looking out of a client's room at Cherokee.

 A typical in-patient bed at Cherokee.

 This is the "nursing-booth' in the hospice rooms. This booth has windows into the conjoined room for the family and the patient's room.

 The Cherokee Indian Museum 

 Fellow student Caity and I pose by a painted bear. These painted bears are located throughout Cherokee, each representing aspects of Cherokee culture.

 A delicious meal fellow students and instructor Niki made for us at the cabin tonight.

 We woke up in the mountains! Our groups view looking at from our deck at the cabin. It was fairly dark when we arrived, so we had no idea how beautiful the view was.

This was the river mosaic on the floor at the hospital. It included animal prints, stones, and fish.

Eve of Adventure

            Tonight is the eve of our trip! I can’t believe it’s come so quickly. In the next few days, I will have the opportunity to tour and observe at the Cherokee hospital clinical site. We will learn about the history of the tribe and see a production called ‘Unto These Hills’, about the tribe’s history. I’m looking forward to learning about Cherokee culture and how it influences their view of health and healthcare delivery.

            I do not know much about Cherokee culture and am nervous that I will offend or unknowingly disrespect a client. I have no familial or regional ties with Native American tribes. My only exposure to Native Americans is what I see portrayed in the media, which is a murky view at best. In doing research for this course, I’ve examined many of the earlier representation of Native American peoples I was exposed to in children’s films, which were incredibly offensive. I’ve also had to look into some of the bias I have about this group. One of those being the belief that they will dislike me because I’m Caucasian, because of the injustices done to them. This is unfair of me, and causes me to be nervous and on the defense, rather than humble and focusing on the learning opportunity at hand.

             In order to learn more about the groups population that we will be observing, I viewed the Eastern Band of Cherokee Indians community assessment and Health Improvement Plan. (Eastern Band of Cherokee Indians, 2015). Three major health concerns that were identified were substance abuse, diabetes, and depression rates (Eastern Band of Cherokee Indians, 2015). Because children’s health is greatly influenced by their family and home environment, it is important to understand the health of the community they are in. I look forward to learning about how the tribe is treating these health concerns in their community and their influence on the next generation. Geographically, the town of Cherokee is located between Swain and Jackson County (NC Home Town Locator, 2016). Swain county ranks 7^th and Jackson 33^rd of North Carolina’s counties with greatest percent of individuals below the poverty level (Index Mundi, n.d.). Socioeconomic income is a factor affecting access to care. The county of Jackson also identified substance abuse and diabetes in their top three identified health concerns in their Community Assessment (Jackson County, 2015, p. 40). It will be interesting to learn about how the region at large effects and plays into the Cherokee populations health. 

            I’m going to hit the hay! We leave the school bright and early tomorrow at 0500. Which means I will be getting up at 0300 for the commute. I’m looking forward to what these next few days bring. Ta-ta for now!

Resources:

Eastern Band of Cherokee Indians. (2015). Tribal health improvement plan. Retrieved from: http://www.cherokee-hmd.com/pdfs/THIPFINAL2015.pdf.

Index Mundi. (n.d.). North Carolina poverty rate by county. Retrieved from: Socioeconomic income is a factor affecting access to care

Jackson County. (2015). Jackson County 2015 Community Health Assessment. Retrieved from: http://static1.squarespace.com/static/51826030e4b04f94760dc52d/t/56687334b204d55efa4065ea/1449685812274/NEW+2015+Jackson+County+CHA_NoAppendices.pdf

NC Home Town Locator. (2016). North Carolina county maps, ZIP code maps, and congressional district maps. Retrieved from: http://northcarolina.hometownlocator.com/maps/

A Client-Centered Healthcare Model

To prepare for this course, our instructor asked us to do some research about the Nuka Model of Healthcare. This model was developed by Alaska's Southcentral Foundation for the Alaskan Native population (Southcentral Foundation, 2016). While this specific model may not be what is being used by the Eastern Band of Cherokees, we were informed that components of this model will be. The focus of this model includes that healthcare is a service, with the client at the center in control of their healthcare (Southcentral Foundation, 2016). This involves active input by the community being treated, asking what they need and want out of their healthcare (Canadian Foundation for Improvement, 2011).

An important component discussed in the Canadian Foundation for Healthcare Improvement (CFHI) videos (linked below), is the importance of building relationships and really KNOWING the client (CFHI, 2011). An example was done over a client named Frank. This client had a mix of chronic complex health conditions that were not effectively being managed, leading to frequent hospital readmission. Rather than continually treating the client with the same plan, the Nuka model of care focused in on the reason's for Frank's readmission by looking at him holistically. They considered the mental, emotional, and social aspects affecting him. Here is a direct link to the point in the video where Frank's case is discussed, its about five minutes long. Give it a look! : https://youtu.be/tLnZ3_AccoU?t=19m49s

This model of care, with its entire service built around the client's active partnership, beliefs, and culture is an excellent way of engaging the client to help them meet their health goals. As the CFHI video's discuss, because the client's health is largely dependent on them carrying out a treatment plan, it makes sense to make a plan with them in the center! (CFHI, 2011). I believe that this model of care would not only be effective in the Alaskan Native population, but in the United State's healthcare system at large.

These were just a few highlights that popped out to me in my reading and watching of material. I'm looking forward to discussing this healthcare model in class and learning more about it. This system is different from what I am used to, and I am still trying to wrap my mind around it. In our courses, nursing student's are taught to look at patient's holistically, with a "patient-centered" focus. I think nursing could integrate even more of these aspects demonstrated in this model. If you would like to look at some of these resources I viewed, the links are included below. I will update or post as I learn more!


References used and resources for more information on the Nuka healthcare model:
Canadian Foundation for Healthcare Improvement. (2011). Southcentral Foundation's Nuka model of care: Rocks, birds and cars (Part 1 of 2) [Video file]. Retrieved from: https://www.youtube.com/watch?v=tLnZ3_AccoU&feature=youtu.be

Canadian Foundation for Healthcare Improvement. (2011). The Nuka model of care: How they did it (Part 2 of 2). [Video file]. Retrieved from: https://www.youtube.com/watch?v=5TfNjYshPsc&feature=youtu.be

Southcentral Foundation. (2016). Learn more about Nuka. Retrieved from:  https://www.southcentralfoundation.com/nuka/learn-about-nuka/