Yesterday was our last day at the Cherokee Indian boundary and today is our last in North Carolina. It is impossible to encompass in this blog all that I have learned while on this trip. I have not been “lectured” about the Cherokee Indian culture nor about advanced pediatric care; I have had the opportunity to experience it all firsthand. Starting from our first day at Cherokee Indian Hospital I have been so amazed at the generosity that this culture exemplifies. The Cherokee culture is made of a very tight-knit community where they protect and care for one another. The generosity that the community shows to each other can be seen through the “per capita” system the tribe uses, free healthcare, free education, and the years of hard work members have done to progress and keep alive the Native American Indian beliefs and values. Their generosity extends past their community however. The CIH was willing to allow us eleven outsiders to step into their world and be observers of their practices and way of life. Not only this, but many of the people we worked with went out of their way to make this a wonderful experience. For example, one of the most highly respected ER nurses Victoria spent lunch with us and educated us about Native American culture, pertinent issues that the community is still having, and ways to advance our nursing careers. One of the things Victoria told us that I will always remember was to always advocate for ourselves. She explained that as nurses, you must be able to stand up not only for your patients, but for yourself as well and if we learned how to do that, we could succeed in becoming great nurses. Victoria wanted us to have such a great experience that she set up a surprise for us students yesterday. We were taken to what is referred to as the Kituwah. The Kituwah is a plot of land that the Cherokees had to repurchase from the government I believe roughly twenty or so years ago. What is special about Kituwah is that the mound in the middle of the farmland is where the Cherokees believe the first Cherokee Indian was created and placed on this Earth by God. I felt so honored to be taken to such a sacred place of the Cherokee people. It showed me the desire that the Cherokee people have for the world to learn about who they are and though I had felt welcome prior to this experience, it made me feel as though we had formed a friendship between our two groups. 

While I have been here I believe I have contributed to improving the health of others by immersing myself in the historical experiences of the Cherokee, assessing their unique health system and analyzing its application to my culture, and grasping the foundations of Cherokee culture and reflecting on how it will affect my nursing care with a Native American patient. Beginning from the time of the first settlers, the Cherokee have experienced suffering and degradation unimaginable to most. Deprived of their land, separated from their families, and forced to assimilate to a system of values and beliefs not of their own, the Cherokee people struggle with this historical trauma to this day. This has inadvertently affected both the mental and physical health throughout the community. What I am able to take from all of this is a deeper compassion for those patients whose ancestral roots are attached to mass suffering. When working with patients such as the Cherokees, I can be more sensitive and exude a deeper and more genuine compassion for the health alterations they experience because I have greater understanding of where their mental, spiritual, social, or even physical illnesses began. 

Despite the historical trauma this incredible community has experienced, they have flourished in the midst of it. Regardless of the opposition they initially encountered, the tribe made the decision to build a casino on the boundary in order to become sole regulators. This allowed them to also be responsible for the entire healthcare system. Since then, the community created a health care system in likeness of the NUKA health care model and it has increased the health of their community in terms of both primary preventative and tertiary care. Patients are now the center of focus and the health care team is dedicated to providing care in a systematic holistic manner. Additionally, now that the community has become self-sufficient they have created health care programs, schools, museums, and tourist sites that honor and keep their culture alive. These new programs are so critical to the Cherokee people because they will ensure the continuation of their heritage by improving the health, education, and pride/self-esteem for all members. 

While reflecting about the different experiences I have had throughout the week, there were many that took me out of my comfort zone. My first day at the primary care clinic was like stepping into a new world. I am not use to a healthcare facility that isn’t fast paced, task oriented, and individual in their approach to delivering care. When observing the employees at CIH, it really took time to wrap my head around how the interdisciplinary collaboration that I was seeing and how it was so effective to providing quality patient care. Another instance where I found myself out of my comfort zone was when we visited with a certified healing touch RN. This nurse taught us all about a new approach to pain management literally called “healing touch”. She showed us different ways to feel energy, re-balance your “chakra” (which are circles of energy surrounding the body), meditation, and how some healthcare professionals believe that just by moving your hands over a patient’s body in certain ways, they can decrease their pain levels. Though I am uncertain as to whether this practice is completely valid, I do believe there is power in touch and I am thankful I stepped out of my comfort zone to try a new experience. 

I cannot believe the end to this trip has come so soon. Though I am eager to see those whom I have missed, I know this has been a once in a lifetime opportunity that has impacted me in ways beyond what I anticipated. My beliefs on health care practices have been challenged while here at Cherokee. I have now seen how a health care system that has been designed based on the patient and culture, rather than incorporating the patient and culture into an already present health care system. I have seen how different disciplines of health care can in fact work together in a respectful and efficient manner. I have seen now how all of this has created better patient outcomes and prospered a once impoverished community. My cultural values have been impacted while here as well. I have experienced different health, social, and spiritual culturally related beliefs while in Cherokee. Though my beliefs and values are deep rooted, the broader understanding I have now of the Cherokee people will only serve my patients better as a future nurse, and myself better as a person in this world. When looking back at my first blog and seeing what my aspirations where from coming to North Carolina, I have accomplished all that I wished too from this trip and I could not be more thankful. 

Below are pictures throughout this journey and the wonderful times we had together <3

Kayla and Victoria of Cherokee Indian Hospital: Tributes to the community.

 Replica of a traditional Cherokee Council House

                                                

       Deanna and I's engagement photo at the Biltmore Estate!

 Tour of the Indian Village


















                Depiction of Jerry Wolfe: Named most Beloved Man

 Kituwah: This is the mound where the first Cherokee was place on Earth by the Creator

        My wonderful instructor and I!

 Friends!!

              Mission Children's Hospital

 Beautiful mornings

                                                                                                                        NICU



                                                                                                    

 Amphitheater where we watched "Unto These Hills": a depiction of the historical events of the Cherokee people












                                                                 
                                                                      Just being silly

Morning runs in the mountains <3

   Lunch at the Sassy Sunflower

 Traditional Cherokee sculpture

















                           Never forget.... "It Belongs to You"

It is already day five of this amazing new journey the eleven of us ladies have ventured on and today has been no exception to the wonderful learning opportunities I have come across. We started our day off at the Mission Children’s Hospital in Ashville, North Carolina. We first met with the nurse coordinator Karen who introduced us to their Pediatric Nurse Educator Ashley. Ashley oversees both the general pediatric floor and pediatric intensive care unit; that means she supervises over 130 inpatient beds between the two floors. Ashley taught us a great deal about their pediatric system. One of the first things I noticed that I loved about this hospital was the large support system they had for their pediatric and neonatal units. The pediatric and neonatal intensive care units are all given designated healthcare team members specifically for their units. For example, when there is a rapid response call for any of the three floors, there is a pediatric physician, nurse, and respiratory therapist that responds to this call and they are hired specifically for those patients. This contrasts a great deal with the typical pediatric and neonatal floors I have been exposed to back home. Most pediatric floors I have come across do not have specified rapid response team members for those patients and there is no sense of “unity” among the three floors; that is general peds, intensive peds, and neonatal intensive care. Another difference I noted was their phenomenal orientation program. When a new graduate nurse is hired at this hospital, they are placed on a six to twelve month “learning plan” where the employee is able to move throughout the floors and see where they best fit and feel comfortable nursing. The administrative staff meet with the new nurses often to discuss their feelings, concerns, and goals in order to see where the best placement is for the new nurse. I have never heard of another facility implementing such a program and I believe it is a very thorough means to ensure quality nursing care and decrease employee turnover rates.

As we progressed throughout our tour we met our new tour guide named Whitney and entered the neonatal intensive care unit. I was beyond excited to have the opportunity to step onto this floor as I hope to someday work as a NICU nurse. I learned a great deal from the NICU about how families and their children were affected by hospitalization. It is not a surprise that the majority of babies in the NICU have been hospitalized since their birth. Whitney discussed with us that while their facility promotes and encourages parents to be present in order to feel comfortable and provide care to the child, this cannot always be done. Mission Children’s Hospital provides care to patients from over seventeen counties; some of them being over two hours away. She informed us that many times parents have other children, they have work that they cannot take off, or they live to far away to be at the NICU 24/7. Do to this, parents often miss out on what is called “multidisciplinary rounding”. The NICU at this hospital has implemented a rounding program where every morning the physician or nurse practitioner, nurse, and other applicable health team members to the child’s care, meet with the parents to discuss what the treatment plan is for that specific day. This is a critical meeting for parent’s to be at as it allows them to be included in their child’s care, keeps them up to date, and gives them a greater sense of control often in circumstances where parents already feeling helpless. One of the ways to combat this issue and continue to provide family-centered care is by using the “transition” area of the NICU. The transition section of the NICU is used when the patient has been deemed stable and is planned to be discharged soon. The patient and family are in a private room where the parents are given education about specialty cares for their child, taught typical parenting skills, and essentially begin to take on the role as the sole primary caregiver to the child. Elements that also instill family centered care of the NICU are the sleeping accommodations in the transition rooms. The NICU itself does not have an area for parents or family to stay the night and so the hospital will rent what is called a “Ronald McDonald” room to the parents if they meet certain criteria. However the transition rooms have pull out beds that encourage parents to stay and become involved in providing care to the child. While I learned much more from out time at the NICU, these were a few of the differences from other health care systems that I felt were critical to promoting holistic and family-centered care. 

After touring the hospital we visited the outpatient Mission Children’s clinic. This is a clinic dedicated solely to pediatric patients and has a vast variety of different types of care they can provide. This facility has pediatric endocrine, pulmonary, neurology, physical therapy, MRI, orthopedics and many other types of units. This clinic was much similar to the Cherokee Indian Hospital we have been observing this week. Its focus is centered on the patient and providing nearly all of the different treatments a pediatric patient may be in need of in one building.

After having learned a great deal from both facilities today I have found myself comparing and contrasting their systems to that of the Cherokee Indian Hospital. As stated previously, the outpatient clinic was similar to Cherokee in that it provides a more holistic treatment facility than most. However I do believe there were more differences to be noted. The Mission Children’s hospital functions more like a western healthcare system. Their hospital is designed as an acute care setting that does not incorporate a multitude of interdisciplinary departments. They also are not as family or culturally oriented as the Cherokee. When discussing with Ashley how they would accommodate a large family in the PICU, she stated that there are strict rules about limiting visitors in the PICU. This is done because they believe that allowing a large influx of visitors comprises both patient safety and healing. Do to this, their patient rooms are not as large as the Cherokee and though they would try to accommodate the families cultural beliefs about visiting, ultimately the policies and rules take priority. This philosophy was the same for the NICU but at an even stricter level. Whitney informed us that the family must create a list of acceptable visitors and once that list is written, it can never be changed. Anyone who is not the parents or grandparents has to be accompanied by the parents in order to visit a patient in the NICU. Additionally, siblings of a patient in the NICU must be vaccinated in order to visit. Whitney explained that the vaccination policy is related to the compromised health status of NICU babies and the recent increases we are seeing in preventable diseases. I believe both health care systems have their advantages and disadvantages.  I am curious and have found myself contemplating if you could realistically incorporate attributes of both healthcare systems, and ultimately what that would look like. For example, could we incorporate the holistic and culturally sensitive aspect of the Cherokee health care system with the progressive and regulated aspects of the Mission Children’s health care system? I am unsure of the answer but after seeing all that I have today, I am confident that health care is an every changing system that will always have its achievements and setbacks. The key is to be a professional that can adapt to the necessary changes needed in order to provide our patients with the best care we whole heartedly know they deserve. 

A side-note to this post is about the last place we visited today, the Biltmore Estate. This estate was built by the Vanderbilt’s in the late 1800s. This was a gorgeous and beyond imaginably large estate with a mansion, multiple gardens, farms, and a winery where the public are invited to come spend the day and relax. Below are a few pictures of the fun time we spent at Biltmore! 

 The NICU:
Stories of  little ones who have overcome greater obstacles than most can imagine.

 Mission Children's Outpatient Clinic: The entire building is designed with bright colors, animals, and fun patterns that help the pediatric patient to feel comfortable and excited about their treatment!

The Biltmore Estate: The picture to the right is a small view of a huge mansion with over 250 rooms. The picture to the right is me relaxing in one of the many Biltmore gardens!

We are finishing our third day here in North Carolina and it has been a busy couple of days. Tuesday June 6^th we had our first clinical day where we spent our time rotating between different units of the Cherokee Indian Hospital (CIH). One of the first things I noticed yesterday when looking at the front entrance wall was the big Cherokee sign that stated “It belongs to you”. This is the fundamental belief of the Cherokee health system. They believe that the health system as a whole belongs to their people and therefore they are ultimately the ones who run it. I spent the first four hours of the day in the Primary care pod. Their system is set up in six different pods. Each pod has two sets of teams and they are each comprised of a physician, a nurse, a case manager, and case management support. I learned a great deal about how their computer system functions and one of the amazing attributes that stuck out to me was their “alarm clock” system. The case manager and support staff have an application for every patient that “alarms” them for every preventative visit the patient is in need of. For example it informs the staff if the patient has had their mammogram, colonoscopy, pap, hepatitis C screening, and many others. I also learned quite a bit about the clinical aspect of this pod and I got to see firsthand how they use the “customer-owner” concept of the NUKA healthcare model. There was a patient who called with complaints of excruciating pain and they could not wait any longer to see a doctor. The case manager could not get the patient an appointment until July, however she and the physician worked together and were able to get the patient a walk-in visit less than an hour after they called. This really showed me how the Cherokee health system respond to their patients’ needs and how the patient’s wellbeing is truly at the core of their practice.

I spent the second half of my day at the urgent care clinic not far from the main hospital. Here the health team members consisted of a triage nurse, an LPN, a lab-technician, and three providers all with varying titles ranging from a nurse practitioner to a physician’s assistant.  It was here that I saw many similarities and differences between the Cherokee health system and our own. The urgent care clinic was similar in that it provided care to patients with a certain severity level of illness, they had a typical triage system, and all of the health team members worked together in the same facility. The differences I noted were first the quick response each provider had when a patient presented to the clinic. Every provider I watched received a patient’s chart and within five minutes was out the door and in the patient’s room doing their assessment. I often find myself waiting for hours at a prompt care back at home because our health care culture does not feel that sense of urgency these providers did. Another difference I noticed was the absence of judgment from all of the staff members. Working in healthcare I hear many professionals place judgment or blame on the patient for their condition before even walking into the patients room. I never once heard any of the staff “shrug” or show animosity towards their patients. I had the opportunity to speak with the LPN whose name was Mary Jo. She was a very nice woman who educated me a great deal on Native American culture and some of the things I found interesting were the complimentary/alternative therapies this culture uses. The CIH has an acupuncture and massage unit designed into their hospital to provide additional healing sources for their patients. Mary Jo also told me of some traditional medicines used in their culture. As an example, wild cherry bark tea is commonly used for fevers and gold stick has been used for asthma. Mary Jo’s two children both suffered from asthma, and she stated that “after they used the gold stick, they haven’t had asthma since” (personal communication. 2016).  Alternative medicines and complimentary therapies are a strange concept to me because I never grew up using anything except traditional medicine. It was a wonderful opportunity to learn about new therapies that have proven to be effective! Another aspect that I enjoyed of Mary Jo and I’s conversation was learning about the child-rearing practices of Native American culture. The Kitnwah Academy is an exceptional boarding school that is grounded in educating their children in the Cherokee culture. Here the children are given a vast knowledge about their history, traditions and practices. They are not only taught the Cherokee language, but are only allowed to speak Cherokee at the school. Mary Jo said this was different from the way she was raised.  She stated that she barley knows Cherokee because there was a time where the government forced children on the reservation to attend to government boarding schools and they were not allowed to speak Cherokee. This was an attempt to detach the Native American people from culture and ways of life. Her mother was a victim of this movement and as a result, her mother was shamed for being Native American and lived in fear about raising her children in the Native American ways. Hearing about the oppression that Cherokee people have had to overcome within just the past hundred years was eye opening. I have only begun to see the generational effects of the trauma and it is evident through their changing child rearing practices.

 After our long day on Tuesday, it was time to go out into the community and learn a little more about our population. We took a tour of the Indian Village which is a wonderful journey where you learn all about the Native American life beginning from the precolonial era up to modern times. I learned about their pottery, basket weaving, and weaponry making skills, we were able to see traditional Indian homes that they used, and were even able to participate in traditional Indian dances that were done in celebration of life and unity. I learned that the people who have the most respect in this culture are the elders. Elders are seen as the people who have years of wisdom and a wealth of knowledge that can be passed down. This is in complete contrast with my culture where unfortunately elders are not given the proper respect or admiration as Native American ones are. Many of the family structures I have seen are traditional in that the male is the leader of the family, the female is the nurturer, and the children are inferior in status. Though males take on the traditional male gender roles, one of the tour guides named Donald informed us that all Native American’s learned how to do everything. He stated “both males and females learned how to hunt, fish, gather, grow crops, and make weapons and baskets. This was done in case one of the spouses were to die” (personal communication. 2016). This was surprising to me but after hearing Donald’s rationale, it made complete sense.

After seeing so much in the past day and a half it has become clear to me that Native American culture differs from my own in a specifically large way; their value is in the community. The community supports everyone. This can be seen by how the tribe provides every member with the “per capita” system, how they provide free healthcare and employ their members first over others, and it can especially be seen in their education system. Their education system is completely one hundred percent free. The tribe gives incentives for excellence in school by paying students when they receive good grades. Additionally, they will pay in full for any one of their members college wherever they want to go. The Cherokee want their community to prosper and become a self-sufficient nation and so the community themselves have been the major support system for all Cherokee members. 

                     
             "It belongs to you"

       Blow gun weaponry and basket weaving                                       


       

                                            

Precolonial home

                                                               Just because