The Sustained, Positive Impact of a Native American Cultures and Health Course on Students’ Education and Practice-Related Choices

Abstract

Objective. To encourage pharmacy students to elect education and practice opportunities in Native American communities, including careers with the Indian Health Service (IHS).

Methods. Students in 2 elective courses were educated on various aspects of contemporary Native American life in urban and reservation environments, including cultural traditions, social and health-related challenges, health access disparities, and cultural approaches to health and wellness. The teachers were Native American leaders and healers primarily from Plains tribes, as well as non-Native American practitioners affiliated with IHS hospitals and tribal health facilities. Students kept reflective journals, and a subset spent 5 days immersed in a rural Navajo community where they lived and worked alongside IHS practitioners and Community Health Representatives.

Results. Student engagement with IHS opportunities was tracked for 11 years. Of the 69 pharmacy students who completed the electives, 11 applied for a Junior Commissioned Officer Student Training and Externship Program (Jr. COSTEP) (8 accepted, 6 completed), 43 requested one or more IHS APPEs (43 accepted, 32 completed, 8 in progress), 17 applied for an IHS residency (1 pending, 8 accepted, 5 completed), and 5 became IHS Commissioned Corps officers. Five additional students accepted an IHS or tribal position, with 3 pursuing a USPHS commission.

Conclusion. Since the first report on the impact of this elective experience was published, the course continues to meet its primary objective of promoting interest in IHS/tribal education experiences and pharmacy practice careers.

INTRODUCTION

In 2007, the first paper describing the content, structure, and outcomes of an elective course on Native American cultures and health was published in the American Journal of Pharmaceutical Education.¹ That paper focused on the impact of the service learning component of the class on students pursuing advanced educational experiences and/or career opportunities in tribal communities.

The 2007 manuscript referenced experiences offered by other programs and identified goals common to courses that adopt a service learning pedagogy.¹ Around and since that time, articles reinforcing the importance of exposing students to experiences that hone cultural competency have appeared in print.^2-9 Examples of the centrality of cultural competency to contemporary practice include the ongoing work of the American Association of Colleges of Pharmacy (AACP) Caring for the Underserved Curriculum Task Force, the inclusion of cultural sensitivity in the Approach to Practice and Care domain of the 2013 CAPE Educational Outcomes, and cultural awareness and sensitivity elements within Standards 3, 25, and Appendices 1-3 of the draft ACPE Standards 2016.^10-12 However, a review of the literature indicates that, while some programs incorporate a brief immersion into their cultural enrichment experiences, the elective courses in Native American cultures and health are relatively unique with respect to their emphasis on career discernment within the studied population. Programs attempting to foster an interest in rural health practice are most similar, as they blend college or school-supported, immersive cultural study experiences with a goal of shaping career choice.^13-14 However, these programs often recruit prepharmacy students presumably predisposed to this career path (eg, from rural communities).¹³ In the electives on Native American cultures and health (PHA 341 and PHA 340), student interest in and commitment to native cultures, people, and careers and their communities are discovered in a less preordained way.

PHA 341 was offered each fall from 2003-2013. As the cost of the school-sponsored service learning immersion limits enrollment to 4-6 students, a concurrently offered elective (PHA 340) was added in 2008 to accommodate student interest. The courses were co-instructed until 2010, when a single pharmacy faculty member became the sole instructor. PHA 340 is identical to PHA 341 with the exception that PHA 341 students participate in a week-long service immersion on the Navajo reservation, give informal in-class “travelogue” presentations on their immersion experiences, and present formal in-class seminars on a targeted health issue or disease state of significance in Native communities. Enrollment in the courses grew from the original 4 students in 2003 to 10-12 in 2011-13, and 12 second-year and third-year pharmacy students enrolled in the fall 2014 offering.

While students enrolled in these electives are predominantly from the pharmacy program, 4 occupational therapy students have also enrolled (2 in each course). In addition, students enrolled in an elective offered through the Native American Studies Program of the College of Arts and Sciences that parallels PHA 340 (NAS 340) attend the same in-class sessions as PHA 340 and 341 students. Several of the students who enrolled in NAS 340 are of Native heritage. Thus, the electives have a distinctly interprofessional and interdisciplinary emphasis that has deepened and enriched the learning experience for everyone.

This paper provides evidence of the sustained ability of these courses to meet their primary goal of encouraging pharmacy educational experiences and practice careers within Native American communities.

METHODS

The impetus for establishing the PHA 341 course and its evolution to the current format has been previously described.¹ The learning objectives outlined in the PHA 341 and 340 course syllabi pertinent to this paper include analyzing Native American health care beliefs, traditions, and disparities through readings and interaction with health care practitioners and healers, documenting reflective thinking about course content through journaling, and stimulating decisions to elect an IHS APPE, IHS training experience, and/or a practice career within a Native American community.

The PHA 341/340 courses were comprised of a series of interactive dialogs with Native American speakers from a variety of Plains tribes, some of whom travelled significant distances to visit with the class. The tribal affiliations of course speakers included Lakota, Omaha, Winnebago, Ute, Ponca, and Navajo. Native American speakers not employed by Creighton University were offered a modest honorarium ($100) and reimbursed travel expenses. Non-Native Americans who practice in tribal communities also served as guest educators. The total enrollment was limited to 20. A large conference room served as the classroom to enable a “talking circle” configuration, which facilitated intimate conversation and invited questions. PowerPoint presentations were rarely employed by the speakers. Rather, verbal presentations took the form of instructive conversation and, at times, storytelling. Campus-based students were not allowed to use computers or other electronic devices in class. Students were expected to show respect for the speakers by looking at them, listening actively and attentively to their presentations, and asking them thoughtful questions.

Every course offering included students enrolled through the school’s distance pathway. Students living in or sufficiently close to Omaha were able to participate in the campus classroom. In the early years, distance students living far from Omaha participated by conference phone, but starting in 2010, they joined the campus class meetings through web conferencing software. Distance students and campus-based course participants (including the speakers) were able to clearly see and hear one another, further uniting the class into a collaborative learning community. Speakers actively included distance students in the conversation, both visually (eg, regularly looking towards the wall-mounted camera) and verbally (eg, specifically inviting distance students’ comments and questions).

Course topics were structured to develop as accurate an understanding as was possible in 15 weeks of the beauty and challenges of contemporary Native American cultures and representative life experiences. The first lessons introduced students to the concept of culture, the diversity of Native American cultures, and the Jesuit concept of vocation, which includes “listening for the voice of the Creator when making important life decisions.” Native American speakers viewed as leaders within their tribe and/or the regional intertribal community then shared their views on contemporary Native American life on reservations and in urban settings. Significant social challenges associated with economic poverty in Native American communities were also openly and honestly explored (eg, alcoholism, domestic violence, contemporary and historical social trauma).

The focus then shifted to steps tribes were taking to address social challenges. Students conversed with current and recent tribal chairmen, journalists, national advocates for social justice, and tribal leaders working to re-establish traditional cultural practices to enrich and, in some cases, heal their communities. Alumni who elected careers as USPHS Commissioned Corps officers then spoke with students about their own career discernment process and described professional life in their economically and geographically diverse practice settings. Students learned more about IHS APPEs, residencies, and COSTEP opportunities from these practitioners. A panel of Native American faculty members and staff from Creighton University then shared their thoughts and were asked to touch on any important areas not addressed in the class schedule. The course ended on a spiritual note, with cultural lessons shared through Native song, blessings, and storytelling.

Students enrolled in PHA 341 spent their fall break in Chinle, AZ (in the Navajo nation), living and working alongside IHS practitioners. The service-learning immersion was funded entirely by the university. Prior to their time in hospital or clinic pharmacies, students provided service to elders living in the more remote areas under the guidance of a Community Health Representative. This 2-day service experience gave students not only the opportunity to interact with elders in their own environment and provide much needed services (primarily wood chopping and cleaning), but they were also able to witness the self-sufficiency and resilience of people living in challenging conditions. In addition, with limited transportation options, students saw first-hand the difficulties these people faced in accessing health care services. Thus, students were given the opportunity to develop a new respect and appreciation for the patients they would care for during their 2 days at the IHS health care facilities. Students also explored areas sacred to the Navajo and interacted socially with people from the community. Because they were housed by IHS practitioners, students had the opportunity to talk through what they were experiencing, thinking, and feeling at the end of each day with professionals who have chosen this career path.

In-class activities for the PHA 341 students included a 30-minute presentation to the class on a health issue or disease state common or problematic in Native American communities. In addition to focusing on drug therapy, they were expected to incorporate culturally-focused discussions related to root cause and risk, incidence, progression, and nonpharmacologic healing practices, as applicable. Presentations were scheduled after the fall break immersion to allow students to dialog with IHS practitioners about how patients with the health issue/disease state they chose to research were commonly treated at their facilities, both through Western medicine and tribal healing methods (eg, herbal therapy, prayer, ceremony).

No examinations or quizzes were given in the PHA 341 and 340 courses; instead students accessed a course website containing a robust array of required readings for each class session, and class attendance was required. Students also kept reflective journals, which they submitted monthly for review by the faculty. In the journals, students often responded to faculty-generated reflection questions, but they were also encouraged to write freely on aspects of the classroom discussion they found compelling. During their service learning immersion, PHA 341 students also wrote daily on 4 reflection questions: (1) What did you see or do today that was uplifting, insightful or inspirational? (2) What did you see or do today that was disquieting, disturbing or problematic? (3) How did these experiences impact who you are becoming, both professionally and personally? and (4) Did you hear the voice of the Creator in today’s experiences? Qualitative evaluation of student journals allowed faculty to conclude that learners had successfully met the first 2 course learning objectives.

RESULTS

The major objective of these courses was to motivate students to elect academic and professional training opportunities in Native American communities and, ultimately, to pursue a career with the IHS or in a tribally-run health care facility. Table 1 provides a year-by-year account of the extent to which this objective was achieved, along with an overall summary of outcomes for the past 11 years. The advanced education and training opportunities tracked are Jr. COSTEP experiences, IHS APPE requests, IHS residency applications and placements, and practice in an IHS or tribally-run facility.

Table 1.

Advanced Education and Career Choices of PHA 341^a and PHA 340^a Pharmacy Students (2003-2013)

More than 60% of the students enrolled in PHA 341 or PHA 340 who were eligible to do so requested an IHS APPE experience in their P4 year (Table 1). APPE requests are made in the fall of the P3 year, and 4 students were in their second professional year at the time of writing. Likewise, only P4 students can seek residency opportunities and, at the time of writing, 16 students were in their P2 or P3 year and ineligible to apply for this postgraduate development experience. Of those now eligible, one-third of PHA 341 alumni and 27 percent of PHA 340 alumni (including 1 current P4) applied for an IHS residency.

Applications for Jr. COSTEP (a Commissioned Corps Officers student training and externship experience) were less frequent, with 30% of eligible PHA 341 students (but none of the PHA 340 students) seeking placement. Students must be in their P2 year to apply for a Jr. COSTEP, as these experiences take place in the summer between the P2 and P3 years. The P3 students enrolled in PHA 341 or 340 were ineligible to seek a Jr. COSTEP experience. Students applying for a Jr. COSTEP had to be willing to go wherever they were placed, and that was difficult for those who were married and/or are caring for children or elderly relatives in their home communities.

Ten course alumni elected a pharmacy practice career in an IHS or tribal hospital or ambulatory clinic. This represented 19 percent of those PHA 341 and 340 students who graduated from the pharmacy program, and also included one P4 who had officially accepted a position in a tribal clinic. Of those 10, 4 completed an IHS residency, 1 completed a Jr. COSTEP (but no residency) and returned to IHS practice 6 years post-graduation, 4 were hired by IHS facilities upon graduation without a residency, and 1 will take a position in a tribal clinic in May 2015. By way of comparison, since these courses were made available, the author was aware of only 3 graduates not exposed to PHA 341 or PHA 340 who elected IHS careers.

Four additional PHA 341 students had expressed a commitment to an IHS career and actively took steps to follow this career path. Of these 4, 1 completed an IHS residency but was denied a commission because of health reasons. Despite being qualified from academic, service, and personal/professionalism perspectives, the remaining 3 did not match with an IHS residency site and accepted other residency offers. At the time, the IHS did not commission pharmacists without an IHS residency, and these graduates elected to pursue other career paths. If an IHS residency and/or commission had turned out positively for these 4 students, there is little question, based on continued, personal feedback from the students, that they would be in IHS practice today, and the percentage of PHA 341/340 students electing or actively seeking an IHS career would have exceeded 25%.

Of the 11 students who graduated in 2014, 7 (64%) completed an IHS APPE and 2 (18%) applied for an IHS residency. Of the 12 current P4s, 8 (67%) elected an IHS or tribal APPE, 1 (8%) applied for an IHS residency and 1 (8%) accepted a position in a tribal clinic. Three out of 4 current P3s (75%) stated their intent to request an IHS APPE.

DISCUSSION

The positive outcomes achieved by the Native American cultures and health electives over 11 years document the power of experiences that shape students intellectually and emotionally. Five former students became Commissioned Corps officers. Four of these 5 are practicing in IHS or tribally-run facilities and 1 plans to return to the IHS after completion of a PGY2 academic residency. An additional graduate returned to IHS practice after 6 years in the chain pharmacy setting, and the remaining 3 graduates are practicing in IHS facilities, with 2 seeking to enter the Commissioned Corps. One May 2015 graduate recently accepted a position in a tribal clinic.

Four additional graduates have explicitly shared that they would be in IHS practice today if they had matched with an IHS residency program (3) or achieved Commissioned Corps status postresidency (1). The three students who didn’t match with a residency program were highly qualified from academic, leadership and professionalism standpoints, and all had PHA 341 experience and 1 or more IHS APPEs. Two had completed Jr. COSTEP experiences. This speaks to the need for additional IHS residency opportunities. Knowing they could not become commissioned unless they completed an IHS residency, students “hedged their bets” and submitted non-IHS residency applications along with their IHS residency bids. Since they did not match with an IHS site, these students followed alternate career paths. Continued expansion of postgraduate education opportunities in IHS facilities is one approach to helping ensure all qualified students who seek an IHS residency have a reasonable chance of placement.

A large segment of PHA 341 and 340 students sought additional academic and/or career experiences in tribal communities, while others discovered this path was not for them. This outcome was equally valuable because even though the goal for the course as a whole was to encourage IHS or related practice, the hope for individuals was professional discernment. Whether students tried unsuccessfully for an IHS residency and subsequently opted for another opportunity or proactively elected an alternative career trajectory, the lessons taught by the speakers could be carried into any practice setting. This fact is exemplified by a 2013 PHA 340 student journal entry.

“I am still interested in Native American health and culture, but not as a career path. The biggest impact this course has had on me is to recognize where others come from, and it makes me want to learn more about many different cultures specific to my area. For example, Springfield has a large Burmese and Somalian refugee population, as well as a large Hispanic population. It would be beneficial to know more about those cultures, family dynamics, treatment options they prefer/take heed to, etc.”

The learning that occurred in the PHA 341 and 340 courses was the “head and heart” variety. Through reading, students gained intellectual insight on Native American cultures and the social and health challenges that continue to be a significant component of life for many Native American people living on reservations or in urban communities. Through dialog, students were able to translate this knowledge into an understanding of the profound impact these issues had on individuals and communities. This understanding often became personal for those who spent time on reservations during the service learning immersion. The open conversations that occurred in the intimate classroom setting sometimes stimulated discomfort among students as long held beliefs and stereotypes were challenged; however, students’ reflective journals chronicled personal growth. Students exhibited a strong desire to learn and be present to gain from the wisdom of the course speakers. Students seldom missed class sessions, even when excused for illness or because of a conflicting special event in a required course. Despite the fact that there were no examinations or quizzes on the extensive readings, student questions and comments often referred to passages they read from the weekly assignment.

The lessons students learned about themselves, both personally and professionally, from conversing with Native American leaders and both Native American and non-Native American healers was also profound. In their responses to reflective end-of-term course evaluations, students shared that they learned of the disparities in access to quality health care in this country, and that they had the capability and the responsibility to do something about it. Terms such as “eye-opening,” “awakening, ” and “watershed moment” were used to express their personal calls to social justice. Through their weekly reflective journal entries, many students demonstrated recognition that people living in economic poverty can be culturally and spiritually rich. Some shared their growing awareness that people who have the least are sometimes the most willing to give. Several commented on the propensity of people (including themselves) to stereotype, and on their recognition of how misleading and damaging it can be. Students also wrote about historical trauma and historical guilt, and reflected on how to move forward without disrespecting the past. They also shared an awareness of how healing cultural traditions can be, and how one can’t ignore culture when treating ill people who embrace their heritage. They expressed professional excitement about how the IHS practice model could empower pharmacists to care holistically for patients in a team-committed environment. Some expressed that they learned what it meant to have a “calling. ”

Perhaps the most dynamic example of the impact of the PHA 341/340 experience on student professional choice came from a graduate who enrolled in the PHA 341 class as a P2 in its third offering. This student elected a Jr. COSTEP and IHS rotation, but life took her in a non-USPHS practice direction after graduating. Five years later, she wrote to say she had been “dreaming about doing IHS” since her second year of pharmacy school and that she and her husband would be seeking positions in an IHS hospital or ambulatory clinic. After visiting several facilities in the desert southwest, they ultimately accepted positions at an IHS hospital in southern Arizona.

CONCLUSION

The impact of the elective courses in Native American cultures and health has been significant on students and faculty members. Students used words like “honored” and “blessed” when referring to the opportunity to have learned from the leaders and healers who came to teach them. Data revealed that the courses met their mission of stimulating interest in exploring/electing practice in tribal communities. It is a long-standing campus-community partnership that continues to benefit all parties, particularly students who report leaving the experience personally and professionally changed for the better.