June 11

Our last night/day here in Cherokee. This was such an amazing journey, I couldn’t have asked for a better learning experience. This was so eye opening and fun to get to experience what we did and learn about the culture. We got to learn a lot and see a lot, but it made it even better the people who came on this trip as well. We learned a lot about ourselves and hopefully have a better understanding of the Cherokee culture. 

This whole experience like I said was amazing. The people here were so warm and welcoming, it couldn’t have gone better. The people were so open about their history, heritage, way of life, how they do things now compared to way back, how things run, their healthcare system, all sorts of things. They answered any questions we had and were so helpful with our learning experience. It was amazing the stories they shared and even better that we got to see firsthand some of their culture. Even though it was an observation learning experience, it was still neat to see how they run their healthcare system, how dedicated they are to patients, how well they work together as a disciplinary team, and how well they promote prevention or do health checks. I can’t really add anything to the health of others but I learned a lot about what they did and can use that for my future patients. It was an eye opener to how they do things and I hope our healthcare system follows suite.

I feel this culture is able to get healthier by keeping up on the prevention and promotions they have started. The more it’s implemented and something is done about it, the more patients will be on board and doing something about their health. It seems this culture really does care and are finding ways to help make a change. I like how they are making a behavioral health unit since it is common there. That way patients have access there at home rather than having to be sent to other towns and away from families. They have a great system where they are at the doctor and the office can see when there is a prevention checkup coming up. They can schedule for the pt right there and the pt is ready to go. I find that so helpful and neat so life is so busy. This also benefits the pt’s health because they are getting checkups to prevent future health issues. For instance, a pt can come in for asthma and the Dr sees that she has her yearly mammogram coming up. That’s one way for prevention of a disease and helpful for future generations. It’s very important to set health precautions in order, get the education out there, and actually help the pt get access. That way it helps them and helps the future. If you want to make a difference, you have to implement something that will help to make a change.

This whole trip was out of my comfort zone. There were little things I had done before but the trip as a whole was hard. It was a great learning experience but it is really hard to not be with family, get out of your every day schedule, not be a clean or control freak, just go with the flow kind of things. I really enjoyed the trip and I am so grateful that I got to experience what I did. It was a once in a lifetime trip and I will be forever thankful for all those involved making this happen from the instructor who made this happen to the nurse educator at the hospital to the ER nurse who took the time out of her day to speak & share with us to all the faculty we came into contact with who shared and spoke so much with us, welcomed us with open arms and didn’t shy us away. Getting to meet the CEO of Cherokee was amazing, the few nurses at Mission Children’s Hospital were amazing to us, getting a private talk with an honorable member of the tribe was amazing to the girls I went on this trip with. Words can’t even begin to describe how thankful and blessed I am for the opportunity. Cherokee people in general were amazing and I thank them a lot for allowing us to come and learn about their culture. I don’t think I was judgmental at all about this culture. I was eager to learn about the Cherokee and what all their culture entailed. What I wasn’t expecting was how much we actually got to experience. It was eye opening especially the personal stories that were shared and what Cherokee history has gone through to get where they are today. I learned a lot and can look at life a little differently than I had before.

June 9

Today was yet another amazing learning experience. We got to take a tour of Mission Children’s Hospital and Reuter which is an outpatient center for children as well in Ashville. When walking in you think it’s just an ordinary hospital-honestly that’s what I thought-but after taking a tour and meeting with a few of the nurses, it wasn’t anything like I expected. I was literally blown away with what this hospital does for children and their families. This hospital completely focuses on the child and their family. I mean it should since it is a children’s hospital but they prove it. Just seeing what they do first hand is amazing work. They have specified areas for peds ie pharmacist, dietician, case manager, flight nurse, respiratory therapist, neurologist, and specially trained nurses to name a few. I thought that was neat since children are a different complexity than adults it only makes sense that they have their own healthcare team basically.

What I found interesting is yes they center on the child but also include the family greatly. We do back home but it doesn’t seem to be emphasized as much as here at Mission. When they have change of shift to report off, they do it at the bedside to include the parents in on what is going on. That way the parents know what is being communicated between the staff and if there are any issues/concerns/questions, that parents are encouraged to comment to speak up. When there are meetings with the doctors or anyone else on the healthcare team that is on the child’s case, the parent is completely involved in the communication as well. They have found this to be very beneficial because the parent is the only people who know the child better than the healthcare team. I thought that was interesting and it makes sense. It should be encouraged more so the family feels more involved and knows what is going on when the case is being discussed right then and there. The hospital even has a sign posted encouraging parents to speak up when there are questions or concerns or care in general for the child. Mission also has a transition room for babies about to go home which I thought was interesting too. This allows the parents to step up and actually do all the work with caring for a child. If the parent hadn’t stepped up yet in feedings or changings or whatever the case may be, this was their time to be caring for the child since they were about to be discharged. This also gives the family time to ask questions and make sure they are ready for baby to come home. What the nurse emphasized about was it’s not just the child you are caring for, its also the family and I completely agree with that. It’s not easy to have a child in the hospital ever so care essentially is for the whole family. While touring the NICU, I like how the family has to show proof of immunizations-specifically children. I think that is a very good concept to have in a high risk area like that. In today’s day in age, there are so many parents against vaccines but this is a way to help keep diseases at bay and help the baby strive so they can go home and have a future. I thought it was very odd though while being in the NICU there weren’t a lot of parents with the children. I don’t know if that’s just a thing down here but when I had a family member in the NICU back home, it was packed with parents or grandparents. I was really surprised especially since the hospital is so family focused.  Another thing I really liked about this hospital since they are family focused is the accommodations they will make for a family. If your child is in the hospital and you have a big family, they will get the child a big room. They also have other rooms available for family to relax if needed. Culture was brought up and since we have just learned about how the Cherokee care for their families, we asked what they would do for them. The hospital is accommodating but only so much due to if they do it for one family like having 80 members show up, then they have to do it for everyone. There are also certain situations like palliative care where accommodations are made as well and I like that. They are caring for this child but willing to make the necessary changes if needed to help both the child and the family. A child needs that support system to be around and it helps them get better. With all the care and accommodating this hospital does for the child & families, it has to be very difficult. I like how like I have mentioned how accommodating they are by providing a bigger room for the child for family needs, other rooms for family, they have family counseling if needed, they have a great pediatric chaplain if needed. One of the things that Mission does is primary care nurse. This means that a nurse that has consistently taken care of a child and knows the child’s case can be requested by the parents to be the nurse to care for them all the time. That way it’s consistency of care and that nurse(s) know everything that is going on with care. The parents also feel more comfortable with this because they have seen this nurse multiple times caring for their child. I like that method and see the benefits of using it. It’s both comforting for the parents and the child to have that consistency since the child is not at a place where they want to be.

After visiting Cherokee Hospital and then Mission Hospital, it’s neat to see what differences or similarities they have even though they are doing the same thing essentially. Cherokee isn’t specific to children needs as in if there was an urgency for care or some kind of specialist needed, they couldn’t do it. I like though that even when the Cherokee is run by the Tribal Council and Mission has their own committees, they focus on the same concepts like including the family on everything and accommodating for them. The hospital if there is an issue has to go to the ethics committee for answers whereas Cherokee answers to the Tribal Council and that is something that is hard for me to wrap my head around on certain cases. I also like that they both have almost all around care in one spot. It makes it easier for the child and families or pts being seen who have multiple needs. What I mean by this is Cherokee has an outpatient center, dental place, imaging, emergency, nurse visits to just name a few right in one place. Mission is the same way in that it has specific health care teams for the children to better their care and be on the same page about the case. Reuter, the outpatient clinic we visited, has quite a few specialties for children as well like orthopedics, disability programs, family counseling, imaging, dental to just name a few. It makes it easy and convenient for everyone involved and should be implemented more back home.

June 7/8

I thought today was very interesting and a total learning experience for me. I really didn’t know what to expect as it was very new and different. I didn’t know if going to the Cherokee Hospital would be welcoming of us students or would they block us out. Would they look at us like were aliens or would they open up about their way of doing stuff here at the hospital and what their culture entails in healthcare. Well thank goodness for open minded people because they were very welcoming. My experience was they were open to answering any questions I had, explaining how they do things here at the Cherokee Hospital, I got see firsthand how they handle certain cases (well the ones I was involved in of course) answered any questions I had about healthcare or their culture. The experience was amazing and I am so glad I got the opportunity to meet with the people I did. During my rotation I got to visit with a PA, LPN/graduated RN, Dr, dietician, nurses who work with the diabetes cases, Behavioral Health case manager, child specialist case manager, and CNA. I am blessed of what I saw and how they were open to speaking with me.

It was an amazing day but like I said I had learned a lot. Here on the Qualla Boundary,  there are not a bunch of ethic committees, hospital boards, or a bunch of hoops to jump through to determine who actually runs the healthcare system. There is one and only one group who makes all the decisions for the hospital and that is the tribe leaders. They vote on things that are needed for the hospital or situations that need taken care of and that is that. There are several members of the healthcare team like other healthcare teams but what makes Cherokee Hospital different from others is the team work they have and it shows. I saw firsthand of how well this team works together and all I can say is WOW! It is amazing what they do for the pt/customer and how well they get things done together. What is neat is that this hospital holds everyone from the pharmacist to case manager to radiology to dental visits. A pt/customer needs help or needs something/to be seen and they work it out for the pt/customers benefit and how quickly it gets figured out is amazing as well. During a checkup, the PA saw that a pt/customer was due for a mammogram and dental checkup so the PA and nurse made arrangements for the pt/customer right then and there. It was so cool and I hope our healthcare system follows in the same footsteps.

Some of the similarities and difference I noticed besides the excellent team work and the healthcare model is behavioral health. It’s something that is handled well here for the fact that there is a need for help and they recognize that. It’s a big issue and here they get help for the pt/customer. Programs have been around for a while unlike back home where it’s starting to show that there is a need for help and more programs. Another thing I noticed is the amount of work this team puts into helping and preventing measures for the pt/customer unlike back home. Here everyone is on the same page about things but back home you have numerous doctors and ideas and tons of meds for one pt. I thought it was it was interesting how in the same office is a pharmacist. The pharmacist goes beyond what I am used to. Here they don’t just prescribe meds they work with the pt/customer and really focus on the meds and treatment they need to make sure they are actually needed to get better. I also thought it was interesting how people here are just as stubborn about getting their annual vaccines as people back home but it is not common at all for parents to not immunize their children.  They also have and give the same meds we do back home for treatment. There are however different forms of medicines practiced in this culture. There is acupuncture and yoga and remedies like yaloroot for sore throats. I’m sure there are a ton more but unfortunately those are kept sacred for that culture only. They won’t share or talk about it and I don’t blame them. Childbearing practices for the Cherokee culture are family centered. The mother and most likely the grandmother are the main caretakers of the children but overall the family consistently takes care of the children. It really is true that it takes a village to raise a child because this culture does prove that. Now there are instances where it’s not always perfect and there are challenges for families and children being raised. What I thought was interesting though is that if there is an adoption to be done a child can only being adopted by someone else of the tribe, no one else. Children can be fostered by outsiders but never adopted.

In this culture you hear a lot about who is highly respected and who has authority. The elders in general are all highly respected and have the highest authority than anyone else in the culture community. Women are highly respected because they run the home, grandmothers are highly respected because they are the caretakers/overseers for everyone in the family because they are full of wisdom and life experience. To make any kind of big decisions is done by the grandmother as well for the very same reason as listed above. For major things, the tribal council has the final say. I observed or heard of both the mother of bringing in the children to the office, the father bringing in the children, and the grandmother caring for the children. There are all sorts of family structures in this community from mom and dad family, unmarried couples family, single parents family, grandparents acting as parents family, foster parents, adoptive parents, or grandma/grandpa/mom/dad as a family unit.

Resilience in children I would think is a tough subject. The actual word means the ability to recover quickly from difficulties. Children have proven to be able to recover more quickly than adults. I do believe that. But it is different for every child and situation. There are times where a child goes through a difficult time and come out stronger than ever from the situation. I believe they just have this ability in already built into their DNA to survive and strive for better. Other children don’t have the structure to achieve greatness and have a harder time throughout life. Some children make it because they are saved and have a great support system and have someone to believe in them, give them faith and hope that they can do it. Some children are saved but if they don’t constantly have the help and support to get passed issues then they will have a hard time as well. Overall, I believe children are very vulnerable to life and each situation is different for every single child. Just because one kid makes it through a tough time doesn’t mean another kid would have the same outcome. And that’s what makes it hard for the future generations because of past issues and it isn’t just the Cherokee culture, it’s all children all over the world. I really believe DNA has a lot to do with resilience but so does having a consistent and nurturing support system throughout life not just as a child.

Monday June 6

First impression of the environment of Cherokee was it seemed friendly and welcoming, it was definitely a touristy area but full of information or art about Cherokee like painted bears throughout the town..a little different from home but overall the people I came into counter with were nice and helpful. Anyone can come here but I feel blessed to be around the Cherokee and on the boundary.

We don't learn much about the Native American's history, only what the "white man" has said or written in our history books. I don’t believe it has anything to do with their history but more our own is when we got to privately talk with one of the Cherokee Indians and he mentioned that he served our country. He was in WWII and actually today was D day back then. He spoke a little about where he was and what he did in the service. He was in the Navy and told us he was there in Pearl Harbor when the signing of the peace treaty happened. Another thing I found interesting was the marriage of man and woman in the tribe. The ceremony usually took place during the Green Corn festival. The man would present meat as a gift to the wife to prove he was capable of taking care of her and also symbolized his manhood. The woman in return gave an ear of corn or a pot containing food that she had prepared herself to represent her womanhood and her ability to care for her husband. The couple would then tie blankets together to literally representing “tying the knot”.

There was also something I never knew but thought was interesting was the 5 civilized tribes. These tribes included the Cherokee, Creeks, Choctaws, Chickasaws, and the Seminoles. Between 1820 and 1830 these tribes were removed from their homeland and moved out west. They learned how to farm instead of hunting, sent their kids to white schools, wrote their own laws and government, and had converted to Christianity. Of course during the removal, these tribes suffered great losses. The Choctaws lost approximately 15% of their people and Chickasaws were about the same. Seminoles and the Creeks tribe were hit the hardest losing half of their tribe. For the Cherokees they lost between 4 and 8 thousand of their own.

Their values and beliefs that are similar or different from your own I feel we have some similarities and differences. I’m a Christian and raising my child to be just that but in a nondenominational church. I don’t want to ever force the issue so if he ever didn’t want to participate in church, I wouldn’t make him. I feel very strongly that it is his decision to make. Another similarity is family is the center. I rely on them so much for help and support with everything in life and I feel that I can relate that to the Cherokees. Story telling is also done in my family. The difference is it usually is for laughs not to make a point or turn it into a lesson like the Cherokee do with their stories. I feel I am a passionate person about a lot of things. Today I was saying don’t kill that spider because it’s back luck. Throw it out the window for the birds to eat but unfortunately it did get smushed. That’s being close with nature right? But really I care a lot about nature; I just don’t make it encompass my life like the Cherokee do.

This culture’s heritage integrates their children in the community. There are numerous stories made for generations to learn about their history, heritage, make lessons out of failures. They even make jokes about life and nature. Children rely heavily on the elders and look up to them for support, guidance, and life lessons. The elders are highly respected and these children look to them to grow and hopefully become as great as the elders. These children are their future of the Cherokee.

Other influences that affect the Cherokee culture I believe that today’s society is a huge influence on the Cherokee Indian. Their way of life is so interesting but it doesn’t make it easy for them at all for numerous reasons. Some Cherokee are completely against Casinos being on the reservation and others don’t want the government to help them. White man has definitely changed the Native American from what they should have been years ago.

Some common threads in this community that is similar to my community is that I noticed they have a lot of the same things we do like movie theatres, grocery stores,  festivals, marriage, hospitals, healthcare, making money doing what you’re good at for some people like basket weaving, they have schools, and churches like us as well. 

 
Overall I learned a lot today while on tour at the hospital, eating lunch at the local Mexican joint, engaging with a Cherokee Indian-(Jerry Wolfe), and touring the museum. At the hospital, I learned about heart to head to heart communication. It was nothing new but the information was shown differently. As nurses we already need to be caring and listening with our heart and head. It’s what makes a good nurse is to be able to do both for a pt/customer. I learned that the Cherokee like it when you look at them when they speak but they may not always look at you square in the eye. They sometimes look peripherally and the exchange of tobacco is a sign of respect. There was nothing interesting about eating at a Mexican restaurant because we do have those back home but what I found different is the way they treat you. It’s not a big deal but I am a LEMON water lover. When I ask for lemon I would like a bunch and back home when I go to a Mexican restaurant, they give me one slice of a lemon and ignore me when I ask for more. I basically give up when at those restaurants but today the waiter gladly got me more. I was taken aback by that and very thankful for the accommodations. I made sure to extra thank him because it was very nice and made by day. Another event was getting to engage with a Cherokee Indian. It was really cool how he took the time to privately sit down with us and talk about things. He had jokes, he shared stories, and the funniest thing was when we asked for a picture with him and he said, “I was waiting for you to ask”. Hilarious!  

June 4

This is going to be a very exciting journey. I look forward to learning new things about where we are at and more about the culture we are going to be having encounters with. I know of the Eastern Band of Cherokees but not much so I look forward to learning a lot. I am eager to learn about their history and how their healthcare compares to ours. I am nervous about this trip. Cherokee culture is very different from mine but I am sure are a lot alike in many ways as well. I am eager to help and learn from this culture but also don’t want to disrespect in any way.

Children have many influences in their life. In the Cherokee culture, children are to be taught and respect their elders. In this tribe, they have healthcare screenings like other cultures do. They have checkup, vaccines, dental checks, and physicals for schooling. This tribe is about putting health first and promoting ways to improve their health. For families not as fortunate, there are many programs in the community to help the family with their needs. Some include family support, domestic violence awareness and help, home health, juvenile services, and nurse-family partnerships just to name a few. I thought it was interesting that since the tribe focuses on family being a united front that a specific focus is on family preservation, reunification efforts, parenting skills education, staff training, and case management for need cases.

My thoughts about Native American culture is I feel very interested it. I like learning about our history and their history and although it has been a sad history for the Native Americans, it’s still really intriguing. My favorite emotional history part I love/very dislike is about the Trail of Tears. It was horrible to read about, it was emotional, and the picture you get in your mind of it is very sad. I can’t believe it happened and I hope history doesn’t repeat itself.  I don’t feel I have any biases, prejudices, pride or stereotyping toward their culture. I feel it’s very interesting and I want to learn more about their culture. This whole journey will be both a learning and eye opening experience.

Nuka HealthCare Model

Part of this journey is learning about new things from a different culture. Something that I have never heard of is the Nuka Healthcare Model. The Nuka Healthcare Model is quite different than what were used to here in Illinois, actually all over the United States in the health care delivery system. The area that we will be visiting doesn’t use the Nuka Healthcare Model yet but we still needed to be informed of what it encompasses. The model was founded by Alaska’s South Central Foundation for the Alaskan Native Culture. This model is different in the aspect that the patient or what they call the customer-owner is in control at all levels of the system. Their goal was to take over their own health care and change how things were being done. They wanted to rely on their values and wisdom from their elders but still keep the best of modern medicine. Their mission was “working together with the Native community to achieve wellness through health and related services”.  Their vision was the “Native community that enjoys physical, mental, emotional, and spiritual wellness”. (CFHI, 2011). They have a variety of health services that include women’s health, pediatrics, dental, family, primary, optometry, residential, elders, family wellness, outpatient, massage, chiropractor, behavioral, and acupuncture care.

Some key points within this health care model are based on the patient and family working together. “Shared responsibility is the individual, the family and the community. Strive to honor the dignity of every individual. We see the journey to wellness being traveled in shared responsibility and partnership with those for whom we provide services. Commitment to quality we strive to provide the best services for the native community. We employ fully qualified staff in all positions and we commit ourselves to recruiting and training native staff to meet the need. We structure our organization to optimize the skills and contribution of the staff. Family wellness we value the family as the heart of the native community. We work to promote wellness that goes beyond absence of illness and prevention of disease. We encourage physical, mental, social, spiritual and economic wellness in the individual, the family, the community, and the world in which we live”. (CFHI, 2011). The health care model is designed around the individual, what they need and what they want. The model is to make good health outcomes, good decisions, good medicine, overall good healthcare.  Nuka framework is to provide care with the patient NOT for the patient and “the aim is a Native Community that is renowned for being healthy". (Gottlieb, 2013).

This is just a little bit about the Nuka healthcare model and what I found interesting. It is different from what I am used but sounds like it is very effective and needs to be implemented more.

References

Canadian Healthcare Foundation Improvement. Southcentral Foundation's Nuka Model of Care. Retrieved from https://www.youtube.com/watch?v=tLnZ3_AccoU

Gottlieb, K. (2013). The Nuka System of Care: improving health through ownership and relationships. International Journal of Circumpolar Health, 72, 10.3402/ijch.v72i0.21118. http://doi.org/10.3402/ijch.v72i0.21118. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752290/