Sandra L. Haldane, BSN, RN, MS

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SL: Tell me about your upbringing.

SH: When I was 3, my dad moved our family from our home reservation, Annette Island, Alaska, to Anchorage. I grew up in a small house with my dad, who was a career air traffic controller, my mom, a former teacher, three brothers, and one sister. While our home wasn't particularly quiet, calm, or filled with joy and laughter, I learned self-discipline, respect, and hard work. All through elementary school, some of my happiest times were being an active Blue Bird and Campfire Girl, shelving books in our little school library, riding the neighborhood on my bicycle with my friends, and playing outdoor games with the ton of kids who lived on our street.

Starting in junior high, I spent most of my summers “on the Res,” staying with my grandmother, aunty, and cousins, and working in the salmon cannery. I also had quite a regular babysitting service and worked part time in an Alaska Native arts and crafts shop. Some of my favorite times in high school were playing my flute in the band and orchestra, and cruising on the weekends with my girlfriends. I always knew I'd go to college but wanted to go far away and live on my own—hence, I ended up in Texas at Baylor.

SL: How did you become interested in nursing?

SH: I started college with the intent of going to medical school but came to the conclusion that I wasn't doctor material. Having done most of my study in biology, I quickly began looking for a major that would accept my credits and provide me with a career. Nursing definitely fit those requirements. While I was happy with this career choice and loved my work, the turning point in my career and the event that I identify as the moment when I fell in love with my work came when I took a job at the Alaska Native Medical Center in Anchorage. It was the nursing work, providing care to my own people, that confirmed I had found the most rewarding and inspirational work anyone could ask for.

Then I was offered a career-changing opportunity when I was asked to participate in a Capitol Hill Nurse Fellowship sponsored by the Indian Health Service (IHS) Division of Nursing. For 6 weeks, I worked with the then Senate Select Committee on Indian Affairs under the direct tutelage of Dr. Pat DeLeon, chief of staff for Senator Daniel Inouye (Hawaii). This fellowship convinced me that I wanted to be more involved in a higher level of policy-making and be able to impact and advocate for our people and our nurses on a much broader scale.

I have never regretted not going to medical school, because I believe nursing has provided me with a more balanced life and the ability to establish greater rapport with those I have cared for. Being able to adjust and fit my work schedule according to family obligations and educational goals has been immensely beneficial. Not having to worry about the amount of time I am spending with a patient and their family, and being more hands-on and interactive with patients and families has been the most rewarding.

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SL: Describe what keeps you passionate about nursing.

SH: Providing care to my people, the American Indians and Alaska Natives of this country, an extremely underserved and marginalized population who face immense health disparities. In addition, knowing that I work among the most dedicated and passionate group of nurses who strive daily to raise the health status of our people.

IHS has been providing healthcare services to the American Indian and Alaska Native people of the United States for over 50 years. Our mission is to raise the physical, mental, social, and spiritual health of our people to the highest possible level, and we strive to do so through 45 hospitals and over 500 clinics and health stations in 35 states. There are 564 federally recognized tribes in the United States, with an American Indian/Alaska Native population of 3.3 million, but we serve only about 1.9 million because the remainder of this population does not live in an area where they can access our services.

The U.S. government has a federal trust responsibility to provide healthcare services to American Indians and Alaska Natives. Services are supported through a series of treaties, executive orders, Supreme Court decisions, congressional legislation, and laws. One piece of landmark legislation, P.L. 93-638, provides for Indian self-determination. As such, almost 50% of our healthcare programs are now controlled, managed, and administered by tribal governments, not the federal government.

Our annual budget in 2008 was $3.35 billion. Funding and staff shortages are a big issue for us. Because of the number of people we serve and the amount of money we are appropriated by Congress, we spend an average of $2,349 per capita on care, significantly less than what is spent on Medicare beneficiaries, individuals incarcerated with the Federal Bureau of Prisons, and federal employees who are insured under the Federal Employees Health Benefits plan. Although we are always looking for ways to work smarter, more efficiently, effectively, and with our eye on quality, we are an underfunded agency.

Our people face significant disparities that the general public probably does not realize. For instance, American Indians and Alaska Natives have a life expectancy that is 4.6 years less than the U.S. all races population. American Indians and Alaska Natives die at higher rates than other Americans for reasons such as tuberculosis (750% higher), alcoholism (550% higher), diabetes (200% higher), unintentional injuries (150% higher), and suicide (70% higher). With additional funds appropriated in 1997 for addressing diabetes, we are seeing significant gains and have now documented a 13% decrease in mean blood sugar (A1C) in diagnosed diabetics, which translates to a 40% reduction in complications. In the past 5 years, the government has invested in health promotion and disease prevention, which has resulted in community wellness centers and a multitude of prevention and wellness programs being established in our communities. We also are investing in the improvement of primary care to better manage chronic illness through better and more comprehensive screening, improved access to appointments, teamwork, consistency of a primary care provider, integrated behavioral health, and care management. So while money is not the complete answer, it does allow for expanded and improved services that can result in improved patient outcomes.

Every nurse and nurse leader knows the impact of the nursing shortage we face and will continue to face, and the IHS is no different. The IHS federal program has almost 16,000 employees: 2,400 registered nurses, 800 physicians, 500 pharmacists, 400 engineers, 300 dentists, and 300 sanitarians. The nursing workforce is equal to the sum total of all other professional groups. Our nursing vacancy rate rose by 2% per year from 2003 to 2009, but this year has declined from a high of 21% to 18%. Very small, remote, rural, and isolated facilities increase the difficulty in recruiting staff. In addition, we have lost our competitive salary edge over the past 6 years, which has resulted in even more difficulty recruiting and retaining nursing staff, especially advanced practice nurses.

To address these salary issues, we are gathering data and putting together a proposal to restructure our civilian nursing workforce salary rates. Nursing satisfaction, however, as we know, is not necessarily dependent on money, so to try and address satisfaction, we anticipate even better nursing staff satisfaction and retention by implementing our improvements in primary care and venturing into the Transforming Care at the Bedside Initiative.

SL: How does being an Indian nurse differ from nurses in other cultures?

SH: Our families and communities are at the center of our lives. We never lose sight of where we were raised and by whom, and we never disregard what or who it took to get us to where we are today. We are expert listeners who bring gentleness and humility to all we do. Alaska is immense (remember that, if you cut Alaska in half, Texas would be the third largest state). Because of its size, healthcare for Alaska Natives is provided through small, isolated, and frontier hospitals and clinics. As such, many people come to Anchorage for a higher level, more complex care. I remember when relatives would come to town from the village to see a specialist or for surgery, and we would readily accept them into our home. If they were hospitalized, we would visit them frequently, and during those times, there were lots of phone calls back to the relatives, keeping them informed of how aunty, uncle, grandma, or cousin was doing.

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There was also closeness in the Alaska Native community, and the hospital in Anchorage was a gathering place. It didn't take long before we would get a call from someone that so-and-so was in the hospital, asking us to check on them. One only had to walk into the lobby of the hospital and see the waiting room filled to the brim with people from all over Alaska, visiting and conversing in their native tongue. Patients and families actively wandered the halls, checking to see who was in the hospital from their village and then stopping in to visit.

Has this sense of community changed between the 1960s and today? Slightly. Today in the new modern hospital, there are TVs and telephones in every room, and people seem a little less apt to wander the halls looking for friends and relatives. And of course, the Health Insurance Portability and Accountability Act (HIPAA) has certainly put a damper on giving out much information on a patient or whether or not they are even admitted. But I must say, despite all the restrictions and modern conveniences, a sense of Alaska Native community still exists, and the hospital is bustling with activity.

I also remember how difficult it was for some of our relatives to stay in the hospital for long periods because they had little access to their native foods and traditional ways. Traditional native healers were not well accepted by the medical establishment until recent times, say the past 10 years. Now there are traditional healers and alternative therapies, such as massage and acupressure, available to those who choose to incorporate traditional healing into their conventional western therapy.

When I was the nurse executive, I thought it would be beneficial to offer healing touch to patients. The nursing staff was thrilled with the idea, so we trained several nurses and began to offer, as much as we could, healing touch to patients. Patient satisfaction was overwhelming, and the nurses who were able to provide this type of therapy found a professional and personal satisfaction beyond measure.

I believe nursing is very much akin to our Alaska Native and American Indian ways of living and being. Nurses bring the art of hands-on healing to the body, mind, and spirit of the patient and family. Nurses are in tune with the suffering of the patient and understand that healing takes place when you have a healthy or content spirit and mind. As with American Indians and Alaska Natives, nurses live the belief that you cannot separate the body, mind, and spirit and that they have to be treated as one in order for a person to be healthy.

SL: What leadership characteristics do you bring to your role?

SH: I think the leadership characteristics that I am most committed to and bring to the role are integrity, inclusiveness, shared decision-making, and humility. Integrity, to always do my best for what is ethically and morally right. Inclusiveness, because healthcare is provided by a team of healthcare staff and the patient and their family. Shared decision-making because there is collective wisdom within the group, and humility to know that my success is built on the success of those around me, grounded in those who have gone before me, and based on the family who raised and nurtured me.

I chose nursing leadership because I truly believe that my purpose is to improve the quality of patient care, improve access to healthcare services, and improve the environment that our nurses work in. Leadership is all about advocacy in many aspects and arenas, and I get a lot of joy out of being in a position to do that.

The positive aspects of being intense are that I find myself focusing intently on completing a job in a thorough and comprehensive manner, and I am an expert listener. I want to make sure that the many facets of an issue are covered so that those making decisions are able to make an educated and well-informed decision. The downside of being an intense person is that it can be off-putting to those who don't know me. People are sometimes quick to judge that I am all seriousness and or even unhappy, when in fact I might just be intent on conveying a message or being very concerned about an issue. Because of this character trait, I consciously try and remain cognizant of how I might be perceived by audiences who do not know me well or whom have had very little interaction with me.

SL: What vision do you have for the future of nursing?

SH: That nurses will embrace and value all types and levels of nursing, fully advocating, supporting, and extolling the value of every type of nursing practiced today. That nursing will be an accepted and active participant at every decision-making table in every healthcare organization. And that nursing will set the bar for evidence-based practice, quality improvement, and patient safety.

SL: Do you think we will achieve that vision?

SH: Whether we will achieve my vision for nursing remains to be seen. In our system, we struggle with a perception that nurse leaders don't do an adequate job of representing the variety of nursing services we provide. For example, we have a system that provides a continuum of care—hospital based, outpatient based, and community/public health based. While none of us are experts in every setting or specialty, as a nurse leader I expect myself and others in nursing leadership positions to advocate and represent nursing and patient care regardless of where that care occurs. Because I do not have public/community health expertise, I make sure I have experts in that particular field of nursing and healthcare readily accessible for consultation. And in fact, I more likely than not will ask them to be present, speak to, and represent those issues.

Fully believing that nursing leadership is the link between the strategic plan of an organization and the point of care, our system is working diligently to ensure that nursing leadership is at the senior leadership table of our programs. Although we have physician leadership at the highest levels throughout our system, the nursing piece is missing in some areas, so we are working to educate leadership about what nurse leaders bring to the table and advocating for a team approach to leading our healthcare organization.

Like many organizations, we are striving to ensure that our staff has ready access to evidence and can readily access tools to determine whether their practice is based in evidence, as well as contribute to evidence. We have actively engaged Arizona State University College of Nursing and Health Innovation and the National Institutes of Health Clinical Center nursing leadership to help educate our IHS nursing staff on evidence-based practice (EBP). I anticipate this will be a long-term process, but every year we see more and more staff engaging and committed to this effort as we provide them with training and support. This reaching out to a fellow federal entity is but one example of what we in nursing are trying to do more of—partnering for a mutually beneficial cause. We are using the expertise and collegiality of a sister federal program, and what we bring to the table is a healthcare system that is rural, population specific, and rich in cultural diversity.

Partnership for IHS and nursing is a critical component of leadership and viability today. As an underfunded program trying to provide care to a population that faces great challenges, we have to be willing to reach out internally to federal partners and externally to professional and private organizations. Partnering will not only help us improve and support our work and workforce, it will help us sustain and expand services to better meet our people's needs. For instance, we know our American Indian and Alaska Native women experience the violent crime of battering at three times the rate of women who are white, and they are 2.5 times more likely to be sexually assaulted than women of any other race in our country (according to the Department of Justice's Bureau of Justice Statistics National Crime database). To address issues like these, our women's health program has worked diligently to foster partnerships with the Department of Justice's Office on Violence Against Women and work closely with Health and Human Services' Office on Women's Health, all in an ongoing effort to improve our women's health and wellness. Partnerships like these foster a team approach to addressing an issue, and we recognize we cannot stand in isolation or work alone to successfully improve the lives and healthcare of our people; we have to pull in anyone who is willing and able to help.

Our efforts to strive for quality care have been immensely enhanced through our partnership with the Institute for Healthcare Improvement. I have no doubt that the work we are doing to improve primary care will become a model for the nation and other countries. As mentioned previously, we have several facilities participating in Transforming Care at the Bedside, and once again, I believe this work will be useful for other organizations that have very small, rural facilities with fewer resources. Thus, I venture to say that our system is well on its way to being the best rural healthcare system in the country, one from which others can learn.

Along the same lines, patient safety and building a culture of safety is tough, despite it being the right thing to do. While we have to comply with accrediting standards, we know that is the minimum to which we should be striving. As such, we are looking at how we build new hospitals and clinics, and what evidence is out there to support the safest patient and staff environment. We have put into place and are continually improving an adverse event reporting system, and we are working with human resources around improved lift policies and trying to educate our staff on how to keep themselves and patients safe.