Last Day in Cherokee

This week has been amazing and it has had a strong impact on my life. The people of Cherokee were so generous and welcoming to our group. At the museum Jerry Wolfe took time to take us back and tell us Cherokee legends. He was so genuine and welcoming of us being there.  Everyone in the community welcomed us openly and was willing to share their history and culture with us. I never imagined I would have learned as much as I did about the Cherokee and about myself. Everyday we were at the hospital key members of their team spoke with us. Victoria, the ER Manager met with us at lunch and told us her personal story and the history healthcare in Cherokee. Her story came from the heart and gave a very real picture of the trauma the Cherokee people have endured.

 On our last day the hospital we had the pleasure of meeting Patty, a licensed social worker that works in the behavioral health department. She gave a talk on trans-generational grief. The lecture explained how the past effects the future generations. I appreciated the education and explanation as to why it is so hard for people to change their ways depending on how they were raised.  She gave an example. ‘A new wife is cooking sausage for her husband and she cuts off the ends before putting in the pan. The husband asks why and she says because that’s the way my mother does it. He later sees his mother in law and asks her why she cuts it that way and she says I don’t know that’s how my mother did it. He then asks the grandmother and she says it was the only way I could put it in the pan.” This story had a funny ending but it demonstrates trans-generational grief and how it effects multiple generations. She also talked about letting go of personal trauma so you would be able to better help yourself and in turn help your patient.

            In this hospital the focus of their model is on preventative care including screenings and vaccinations. They also see the patient as a whole and assess their emotional and physical well being. They do not just focus on treating with medications which is a more common practice in Western medicine. That practice is one of many things I will take away from this trip as a future nurse. I will focus on mental well being especially in cases of patients being inconsistent with taking their medications. It is important to look at all aspects of their life. I was not able to interact directly with patients but I was able to see the healthcare team make their patients a priority and attend to their needs.  

            I think the new model practiced at the hospital will help improve the health of their tribe and the community around them. As I mentioned before there is a large focus on behavioral health and I think that is going to be the key to overall better health in their community. After learning about trans-generational grief I understand better the emotional trauma that still effects many members of the tribe that has led to problems with drugs and alcohol. Currently, the younger population has a rampant drug addiction problem that is starting to be addressed more by the tribe. They are putting more restrictions and required financial classes for per capita distributions. Hopefully, this will help curb wasteful spending and lead to the people having more financial stability.

            The hospital was designed with many aspects of the Cherokee culture so the members of the tribe would feel like it was their own and they would feel comfortable coming in for care. This helps with healthcare and keeping the culture alive. By having artifacts and incorporating traditions the Cherokee will always know where they came from. The schools also focus on the children learning the native language. One of the schools requires the parents to speak Cherokee only to the children. They are doing this in an effort to keep the language and culture alive in their youth. By doing this it will preserve their heritage for generations to come. The museum, Indian Village, and Unto the Hills performance all were excellent ways to bring in the outside world to their area and help keep members of the culture engaged in their history and culture.

            It is important to keep the culture alive within the community it gives them a sense of their history and pride. It is an important part of a person’s identity to know and understand their culture. It is a way to bring everyone together for one common interest giving everyone a sense of community and family. Culture is a way to pass down traditions through the family.  The Cherokee culture is unique and dying off with the elders. It is important to teach it to the children to keep it alive.

            This week we learned so many things and were exposed to a different way of life. On Friday we met with Patty from behavioral health she gave us a presentation about trans-generational grief. This subject hit home in so many ways and brought out emotions in me that I was not expecting. It was an excellent way to end the journey and gave me something to reflect upon when I got home.  After that we had an introduction to Healing Touch training it was awkward at times when we were trying to feel each others energy I think most of us were out of our comfort zone including me. I think there is a valid science to this method but you have to open to it and believe in what you are doing. Even though it was a little different we had fun with the experience.

            Reflecting back on my expectations for this trip I think they were exceeded. I thought I knew or understood their culture but I only knew a tiny bit. All of the talks with elders in the communities gave me so much more information about the Cherokee that I could not have found in a textbook. I was not sure what the boundary would look like and it looked like any other small town. The Cherokee people was very welcoming and thoughtful. I was not sure what to expect but everyone was very open about the community and how they perceive healthcare and that many are more comfortable seeking medical attention. I did not know the hospital had to work to gain trust because many of the older generations were unwilling to come in because of they way they were treated under the previous system. I was able to witness their healthcare model in action I was not sure what to expect but it was so refreshing to see an interdisciplinary team in action. Everyone was respectful to each other and worked together.

            I am so honored to be a part of this experience and to have gone on this trip. I will be forever changed by the interactions we had with all the members of the community. 

Today we had the opportunity to get a tour of Mission Children’s Hospital in Asheville, North Carolina. We also were able to tour the Mission Children's Hospital Reuter Outpatient Center. It was interesting to see another hospital and how their pediatrics unit operates. My only health care experience to a pediatrics or neonatal unit was in clinical at Unity Point. Unity Point is a level 2 neonatal unit and they transfer all babies requiring ventilation to another facility better equip to handle and care for the baby. Mission has a unique setup in their NICU that helps keep their babies within the unit. The unit includes RN’s, CNA’s, hospitalists, nutrition, social worker, respiratory therapist, x-ray capabilities. They try to do as many procedures and tests on the unit to limit the neonates exposure to germs. Another unique feature is the rounding that is completed with a member from every discipline and the parents are invited and encourage to attend these meetings so they know and understand the status of their baby.  This allows for consistent care for the baby. The nurses also have the opportunity to advocate for their patient and make suggestions for their care.  

The rounding that is done at Mission on all floors tries to make accommodations for the family to help make the child’s stay less stressful.  One unique feature on the pediatric floor at Mission was a procedure room that is used for all procedures done that will hurt or agitate the child. The room is meant to be a safe place so nothing is done is done that will make the child uncomfortable. Also the toy room is a hands off room for the nurse, meaning they are not allowed to go in there to give medications while the child is playing. These ‘safe places’ for the children in the hospital help them maintain a sense of normalcy within the hospital and allow the child to rest and know nothing ‘bad’ will happen to them in their room or in an area that is meant for play. Depending on the floor visitors maybe limited on the general pediatrics floor the patient is allowed multiple visitors, on Pediatric ICU there are only 2 visitors allowed at a time and a parent can spend the night. In the NICU it is a little different, the parents are able to list up to 4 people that can be with the child and then other people that can visit the child with a parent. This list cannot be changed at any time during the child’s stay.

Another unique feature is the transition rooms that allow the parents to stay with the baby that is still on the monitor to prepare for taking the baby home. This allows the parents to get accustom to taking care of the babies needs rather than relying on support from the nurses. It better prepares the parents and builds their confidence to take care of the baby at home. It also allows them to understand how any monitors sent home work and how to handle adverse situations. Also, once a child is admitted the parents can pick a primary nurse that will care for their baby anytime the nurse is on shift. This provides comfort for the parents and continuity of care for the baby. Mission takes many steps to apply family-centered care.

At Unity Point and Mission they use Child Life Skills workers that advocate for the patient to keep them comfortable and help relieve stress. Child Life Skills also educate the child about procedures they will receive using play or toys to demonstrate the procedures to help relieve anxiety and fear. 

At Reuter Outpatient Center they had a room setup with a child size MRI machine and doll. It looked very similar to the real thing but it gave the chance for the child to play with it and understand what to expect before the procedure. Also, within the MRI machine they have 3D goggles that allow the children to watch movies. This helps them stay still and relaxed during the lengthy MRI.

Previously, this week we were at Cherokee Indian Hospital which is a 22 bed facility so there is no comparison to the volume or acuity at Mission Children’s Hospital. The Cherokee Indian Hospital actually transfers many moms and babies to Mission for care. One major difference between the two areas is the Cherokee has a small town atmosphere where as Mission is in a major city and the hospital gigantic is compared to Cherokee. I cannot imagine how stressful and intimidating it must be for the Cherokee to go to Mission for care. At Cherokee the culture and practices are encompassed in the care whereas Mission treats patients from the Eastern side of North Carolina.

It was beneficial to go see the Mission Children’s Hospital today because many of the Cherokee Hospitals refer to it but I have never seen. I understand more why some Cherokee will not go to Mission for care. It must feel like they are going to a different world that is very busy, fast paced. This is a challenge for health care workers at Cherokee because they have to convince them that it is necessary to go there for further care.

One thing that stood out to me at Mission Children’s Hospital was the nurses and the genuine care and love for the children they take care of. One of the nurses gave us some very good advice. She explained that working in the NICU is tough and emotional. She said she cries at times in her car or in the shower after her day has finished. She said the day you stop crying is the day you need to start looking for something else to do in nursing. She said you have to care and be invested in your patients. Be ready for emergencies but allow yourself let your emotions out at the end of the day. I will take that advice with me as I move through my nursing career. 

Resilience

Childrearing practices in the Cherokee people are expected of all members of the family. The Grandmother is usually looked to for advice and many times makes all the decisions in the family. There is a respect in their culture for their elders, they are looked upon as having a great wealth of knowledge. The tribe has authority over the people and things that happened within the Quala boundary. In their history the entire family lived within the same household including several generations under the same roof. This is still practiced today is some ways. Many mothers are young so they are still living with their mother who then becomes responsible for the grandchild as well. I heard of many grandparents taking care of their grandchildren when the parents were unable to do so.

At the hospital I saw two sisters come in, one of the sisters was having a pain in her shoulder. I noticed the other sister spoke and told the doctor about her sister’s pain and even describing how she was reacting to the pain and telling the doctor what she was doing to manage. The actual patient said very little to the doctor. Both patient and sister were treated equally and the doctor took all the information into account while providing care. He addressed them both and explained the treatment plan so they would both understand. This demonstrated the physicians desire to respect the culture and view both women as being viable sources of information. It was a noticeable difference from how I am accustomed to care back home.

            Resilience in families is essential to proper development. The family unit functions together and the ability to respond to stress and trauma are essential to child development. There will always be obstacles to overcome and teaching a child these skills are lifelong. A child needs to be protected and cared for to help it feel safe. When these basic needs are not met the child is affected and will have trouble coping with stressors as they get older. Not having coping mechanisms as an adult can lead to poor choices and decisions in one’s life.

             Things such as nutrition, shelter, living in a safe and nurturing environment will affect the ability for a child to be resilient and capable of dealing with life’s stressors. As parents or members of a community it is important to intervene in children’s lives that are not having their needs met. This is why it is essential to have agencies in place in the community such as Child Protective Services. The sooner a child is removed from a neglectful or abusive home the better because it will give the child a chance to recover and be placed in a more suitable environment.

            Children must be protected they are a vulnerable population and they need the support to grow into a health adult that will be able to cope with adulthood and the challenges that come with. If not as the child grows up it is likely they will have difficulties in school or finding employment. Or turn to other means of coping like drugs and alcohol. This is something we have learned about in the Cherokee people. Many of the youth that were raised by parents who grew up in boarding school were never provided with loving care or a nurturing environment and this has led to repent drug and alcohol abuse. Poor spending and lifestyle choices. These children are then unable to provide nurturing care for their own children causing the cycle to continue.  Strides are being made in the community to change this with free prenatal care, behavioral health services to help with treatment of drugs and alcohol. Then they are taught coping skills and ways to avoid use of elicit substances when life gets tough. Resilience is an essential skill for every human being and necessary to navigate life.  

First clinical rotation at Cherokee Indian Hospital

Tuesday, I had clinical at the Cherokee Indian Hospital. I was able to learn more about their healthcare system. The healthcare system is run by the Tribal Council. They make all the decisions about how health care is implanted and what services can be offered by the hospital. The hospital team in the primary care setting are called Pod’s which consist of 12 teams, within 6 Pod’s. In these Pod’s that included a physician, physician assistance, APN, nurse care manager including RN’s, LPN, CNA’s, CMS, CMT, pharmacist, and a behavioral health. The CNA’s and LPN actually work as assistants the doctor and nurse case manager. This team works interchangeably with the patient to provide care.

At one point during the day the nurse told to always respect and treat my support personnel with respect and gratitude. She stated she would not be able to do her job without her CMS. I appreciated her statement and acknowledgement that support personnel are critical to make a unit. I loved sitting back and watching them all work together. It felt like they wanted to be there and they loved their jobs. In my experience on the hospital floor it always feels rushed and the small gestures or gratitude is not always seen.  There is an urgency in the hospital but there is usually an underlying tension or high stress feel from all working on the floor.

When I was working in the Pod the case manager received a call that a patient walked in without an appointment. She met with him and he advised a new medication was not working. She put in an order for the doctor to sign requesting to change his medication. She said those types of situations happen frequently. The flexibility shown by the staff to accommodate the patients was impressive. I do not feel in my experience that my provider every tries to immediately resolve my issues or concerns. I am usually told I need to make an appointment or I will go ask the doctor and call you back later.  At the Cherokee Indian Hospital the nurse can submit the order for the medication change to the provider. He is literally sitting right behind her so she can even ask him a question and get an immediate response.

I was also at the Immediate Care Center (ICC) where I was able to observe the triage nurse. This environment was different the hospital but I noticed the same things. There were multiple levels of health care professionals working together in a supportive environment putting the patient first and meeting or exceeding their needs. The patients were seen quickly, labs such as strep tests were processed and medications were dispensed.  It was a very well run facility that has volumes of 60 to 80 patients a day. Many patients use the urgent care center as a primary doctor rather than going to the hospital. The nurse remarked that it was because “they want to get in and out and not deal with the preventative screenings and vaccines offered at the hospital.” So there is still some resistance to the holistic approach for patients but the ICC team doesn’t look at this as a problem they just try to address what they can when the patient comes in and they ‘track them down’ as needed. She mentioned it was a small community so at times she would stop at their house to get them into the clinic.

The other aspect to the Cherokee culture is the use of commentary or alternative medications. I asked the triage nurse at ICC about the use of not prescribed medications. She stated there are still many Cherokee that use herbal or natural remedies for their aliments along with prescription medications. I asked if the alternative practices were shared with the physician and she said “no, it’s only discussed within the tribe not with outsiders. “ When we went to the Cherokee Indian Village they talked about the medicine man using plants and herbs to heal the people. Their belief is that any sickness can be cured with something from the Earth. Our guide talked about using yellow root for a sore throat. He said if you suck on it or drink it in a tea it will go away faster. The biggest impression I have gotten from this experience is they are trying to do everything possible to hold on to their culture and traditions so it won’t die with the elders. 

Painted bear statues can be seen throughout town

Baskets the Cherokee make

Animal pelts used for trading

Cherokee folk lore

Museum

Smoky Mountains

First day in Cherokee

We arrived to the area at night so we were unable to see the surroundings. I awoke to the mountains in the foreground. They had a majestic feeling as the mist was rising off of them. I remembered the mist after we met with Jerry Wolfe and he told us stories about how they communicated to the Great Spirit with the sounds of the drums or the smoke from a peace pipe because it drifts up towards the Great Spirit. The mountains give the perfect back drop for the stories he told us.

            It was very interesting to learn about how the tribe leaders make decisions in the town including who is in charge of healthcare. When Kayla said they gave us behavior health and I did not understand what she meant until she explained the tribes role.  Most of the healthcare practices are done in the home and the natives delegate what the hospital can and cannot do. The hospital will begin to offer behavioral health services including detox and substance abuse. It was interesting to know of the 18 available beds in the hospital usually 3 beds are taken up with people detoxing. The prevalence of drugs and alcohol is very high and it is the cause of many visits to the hospitals. I think I knew it was an issue but was surprised by how much it consumes the resources and affects everyone in the community.

            We had an unexpected treat when we went to the Cherokee Museum and saw Jerry Wolfe, a highly respected elder in the community. He took us to a room to talk. He started to the talk by translating the Lord’s Prayer in Cherokee. It was beautiful to hear him say the line in his native tongue then speak the English line that I have recited myself since I was a child.  It was such an unexpected experience and it was a nice way to begin our talk because it showed I had a common belief the same as him in a higher power.  It was fascinating to see how the two cultures and beliefs have become intermixed over time. I think it demonstrates the Cherokee people’s strength and tolerance since the Europeans immigrated to the United States.  

            The hospital did an outstanding job integrating the Cherokee culture and traditions into every aspect of the building.  Since they do wellness visits and prenatal care at the hospital the children always see reminders of their culture. I think the artwork in the pediatric waiting area will evoke curiosity and dialogue with the child and their parent. It was also interesting to learn about the private school for the Cherokee children.  The school requires the children to learn Cherokee dialect and the parents are also expected to only speak Cherokee to the children at home. This demonstrates the communities’ effort to keep the Cherokee heritage alive otherwise it will die off with the elders.

            The other surprise was how the Qualla Boundary looks so much like any other small town in America. There were restaurants, gas stations, even a McDonald’s, I guess this shouldn’t surprise me but I didn’t realize how open the area was.  I guess I expected gates or it to be more restricted. It very well may be in some parts but I could not see that today. We pasted several churches which indicated members of the community practiced their faith and this was also evident when we met with Jerry Wolfe.

            Another aspect of the community that is similar to Peoria are the varying areas of poverty and the active drug and alcohol abuse. In our own community we struggle with these same problems and the families and children suffer. In Cherokee they are trying to make changes to stop the abuse but it is difficult to do without full support from the elders. The hospital has identified that if they do not solve the mental health issue then they will never be able treat any of the other medical conditions. I agree with this methodology. I think it applies to all areas of health care. Especially, when you think that most of these people are involved in children’s lives so it makes the need for a more intensive behavioral health unit that more urgent. Children cannot thrive in an unstable environment. If the parents are not able to get the help they need the children of Cherokee will suffer and most likely repeat the same destructive behaviors as their parents.

            I am excited for what tomorrow brings. We will have our first rotation at the hospital. I cannot wait to learn more about this unique culture. 

Thinking that I am leaving in less than 24 hours on this little journey to North Carolina is exciting and makes me a little anxious because I am unsure of what is to come in the next week.  I am leaving my family for a week, something I have never done. I think I am more scared about it than they are. J

But I will not lie I am very excited to go on this trip, I think it will be fun and educational.  I am also curious to learn more about the Cherokee and their culture. It will be interesting to tour the hospital first and then go to the museums before starting clinical rotations. It will allow us to get a better understanding of their hospital and what it is trying to accomplish for their communities overall heath.  I want to learn and try to understand their delivery of healthcare. The Nuka model has a unique and very different focus than the traditional Western model we are accustom too.

I am nervous about starting clinical observations because it is in a different environment than what I am used. I am concerned that I may say or do the wrong thing. The last thing I would want to do is offend anyone. It is comforting to know I will be with two other classmates.  But I am also very excited to get to see a variety of patients in different age groups. It’s been about 6 months since being in my Peds/Ob clinical rotation so it will be nice to get some interaction with that patient population.

According to the US Census in 2014 the median income in the counties surrounding Cherokee is $21,658 to 37,878 is considerably lower than the national average of $53,657. Living in poverty has a negative effect on the entire family especially children because there is an increased risk of mortality, medical conditions, depression, abuse and violence within the family. These make the children on the reservation and in the surrounding counties more susceptible to adverse situations including neglect, abuse, poor nutrition and a lack of access to health care. The Eastern Band of Cherokee Indians, Public Health & Human Services is making strides to combat this problem with programs like Safe Babies Program for maltreated infants & toddlers. The program works to protect and prevent trauma to the children in the tribe. They focus on educating the parents and provide mentors to guide and develop positive parenting skills. There are foster care programs to help the children while the parents are working on getting better established. When researching foster care 70% of Native American children are initially placed with relatives compared to 35% for other races.  This tells me the importance of family and community in the Native American people.

I have never had personal interactions with Native Americans but I am eager to get the opportunity to have this interaction. I do not feel I have any preconceived notions or bias towards this population other than limited knowledge. Documentaries we watched in previous classes highlighted the lack of revenue besides casinos and tourisms. That type of environment lead to poor lifestyle choices such as alcohol and drug abuse. I am curious to see how widespread that problem is and its effects on the community.  I am however impressed by their strong connection to their heritage and cultural traditions and ceremonies.  I think they may still be leery of outsiders because of their history after the United States was colonized. I think this is an understandable reaction. I will not let this affect my experience because I am more interested in learning about them and how I can use that information as a nurse in practice.

Reference

Jordan Institutes of Family. (2015). Management assistance for child welfare, work first, and food & nutrition services in North Carolina. Retrieved from: http://ssw.unc.edu/ma/

Public Health & Human Services. (2016). Family safety. Retrieved from: http://www.cherokee-hmd.com/family-safety/index.html

U.S. Census Bureau (2015, December). Median household income of the total population by county: 2014. Retrieved from: http://www.census.gov/did/www/saipe/data/highlights/files/2014/F1_MP_14.pdf