Indigenous values and world views informed pedagogical approaches in an Aboriginal Nursing Cohort Initiative (ANCI) in Canada (Aboriginal Nurses Association of Canada, 2006). In this article, we use the term indigenous to signify the First Peoples of any region or country. Although there is more diversity among indigenous peoples and groups than similarities, commonalities include strong connections to natural resources (land), distinct language, culture, beliefs, and social, economic, or political systems (Gracey & King, 2009). Indigenous peoples tend to form nondominant groups of society; yet, they resolve to maintain and reproduce ancestral environments and systems (Gracey & King, 2009).
This article describes an innovative educational program for indigenous students pursuing a baccalaureate degree in nursing. In prerequisite and beginning nursing courses, a cohort strategy facilitates peer support and incorporates the indigenous value of interconnectedness (Hampton & Roy, 2002; Martin & Kipling, 2006). By establishing an academic program with consistent instructors and advisors (i.e., continuity of instructors and advisors), small groups, tutoring, manageable course loads, and a culturally supportive environment, a path for success was forged.
The contextual nature of indigenous peoples’ education in North America will be discussed, as the past continues to shape the way in which indigenous students experience and respond to teaching and learning. Historically, many barriers prevented North American indigenous peoples from pursuing a path to college or university. Reasons for low participation and completion rates of indigenous students in postsecondary education are primarily identified as structural and include challenges in secondary education, language and cultural differences, and the effects of discrimination (Association of Canadian Community Colleges, 2005; Curran, Solberg, LeFort, Fleet, & Hollett, 2008; Pijl-Zieber & Hagen, 2011).
The historical context and the relationship between North America’s indigenous peoples and formal or “Western” education cannot be ignored (Hampton & Roy, 2002; Keohane, 2009; Martin & Kipling, 2006; Pijl-Zieber & Hagen, 2011; Smith, McAlister, Tedford Gold, & Sullivan-Bentz, 2011). Aggressive assimilation was the model of education forced on North America’s indigenous peoples (Hampton & Roy, 2002; Keohane, 2009).
A significant and tragic aspect of North America’s history with indigenous peoples was the installation of residential schools and Indian reservation schools, with their aggressive policies and procedures, that were funded by federal governments and administered by the church (Keohane, 2009; Martin & Kipling, 2006). For example, North America’s mission of assimilation resulted in removing indigenous children from their families and communities, with the resultant loss of life (high mortality rates in boarding schools), language, culture, values, world views, and the experiences of family and community life (Hampton & Roy, 2002; Keohane, 2009; Martin & Kipling, 2006). The legacy of Canada’s residential schools, which began in the 19th century and lasted until 1996, shaped an intergenerational mistrust of the dominant culture and a diminished value of formal education (Hampton & Roy, 2002; Martin & Kipling, 2006; Pijl-Zieber & Hagen, 2011). As an outcome of mistrust and disenchantment with Western education, high school dropout rates among American Indians/Alaskan natives in the United States are almost double the national average, and only 7% of Canada’s Aboriginal population has a postsecondary education (Chapman, Laird, & Kewal Ramani, 2010; Orchard, Didham, Jong, & Fry, 2010). Therefore, indigenous youth have limited opportunities to access professional role models within their home communities (Orchard et al., 2010; Smith et al., 2011).
In North America, indigenous peoples have not only experienced a travesty in the realm of education, they also have been subjected to health disparities due to economic and social marginalization (Adelson, 2005). Globally, over 370 million indigenous peoples experience low standards of health (Gracey & King, 2009). Health inequities experienced by North America’s indigenous peoples are similar to those encountered by indigenous peoples around the world. North America’s indigenous peoples experience an infant mortality rate one and one-half to three times higher than Caucasians, adolescent suicide rates two to seven times higher than in the general population, and a higher incidence of chronic diseases (Adelson, 2005). More than half of indigenous children live in poverty in North America (Adelson, 2005).
One percent of the American population is composed of American Indians, Alaskan Natives, and Hawaiian Natives (Norris, Vines, & Hoeffel, 2012). In Canada, indigenous peoples represent 4% of the population, and in some provinces this percentage is as high as 10% (Statistics Canada, 2008). In North America, this population is growing and young; the median age of Canada’s Aboriginal population is 27 years, which is 13 years younger than the mean age of its non-Aboriginal population (Statistics Canada, 2008).
To meet the complex health needs and to provide culturally safe, quality care of indigenous communities, a representative workforce must be developed (Anonson, Desjarlais, Nixon, Whiteman, & Bird, 2008; DeLapp, Hautman, & Anderson, 2008; Gilliss, Powell, & Carter, 2010; Health Canada, 2005). Increasing the numbers of indigenous peoples in the profession of nursing is recognized as being essential (Aboriginal Nurses Association of Canada, 2006; Arnault-Pelletier, Brown, Desjarlais, & McBeth, 2006; Gregory & Barsky, 2007; Katz, 2005; National Aboriginal Health Organization, 2006), but less than 1% of North American RNs self-identify as having indigenous ancestry (Health Canada, 2008; Martin & Kipling, 2006; Minority Nurse.com, 2009; Smith et al., 2011). In response to issues of recruitment and retention of indigenous people into health careers, indigenous leaders and several departments within the Canadian government developed a framework to support indigenous students interested in pursuing health careers. This framework was articulated in the Aboriginal Health Human Resource Initiative (AHHRI) in 2006 (McBride & Gregory, 2005). A long-term goal of the AHHRI framework is to optimize a workforce that is able to meet the needs of indigenous communities (McBride & Gregory, 2005).
An Educational Innovation: Two Paths to Success
In response to the AHHRI, the ANCI was developed in 2007. Faculty members and staff from the Access Program and the school of nursing at the University of Manitoba designed and implemented a unique educational program to meet the needs of this student group, which was composed of diverse indigenous peoples. The ANCI’s objectives are to improve the (a) contribution of mainstream baccalaureate nursing education to the development of more indigenous nurses, (b) indigenous students’ ability to succeed in pursuing education through provision of educational and counseling supports and through access to financial aid where needed, and (c) cultural appropriateness and effectiveness of education and clinical practice to meet the needs of indigenous students and communities.
The diversity of student candidates for the ANCI is reflected in the educational backgrounds and age ranges; applicants derive from remote, rural, or urban settings, with various degrees of knowledge and experience with the indigenous culture. Although we use the term ANCI students as a common aggregate, these students are quite diverse.
Applications are carefully screened to determine the best route to ensure success for each student. A face-to-face, 1-hour, semistructured interview identifies potential barriers to success. During the interview, the applicants are also presented with an opportunity to reflect on their social supports, personal strengths, and learning needs. Attention to these issues at the outset of the program facilitates students’ capacities for a smoother transition into an urban and postsecondary setting (Evans, 2008).
Pathway One—Transition Year
Some applicants are directed to a newly developed Aboriginal Nursing Cohort Transition Year Program, where academic preparation and mentoring prepares indigenous students for future courses. English and science courses are offered, including a prerequisite course that provides information about traditional indigenous knowledge and Western science. Issues related to discontinuity between indigenous world views and Western sciences are addressed by facilitating a link between the two world views, as supported by Pijl-Zieber and Hagen (2011). In the second term, a course titled Introduction to Health and Healing provides information about indigenous and Euro-Canadians’ understanding of health and health promotion.
Pathway Two—Aboriginal Nursing Cohort Initiative
Candidates with a sound academic history and social support are encouraged to enter into the second pathway—the ANCI. Academic success at a secondary level is assessed through review of official transcripts and two letters from referees. The degree and nature of social support is determined during the interview process. The first year of the ANCI generally mirrors the course selection and sequencing of the first year of other potential candidates in the school of nursing. The differences are the cohort approach, reduced number of courses per term, smaller class size, tutoring, and consistent academic and personal counseling. Five hours of free tutoring per week are offered by the instructor for each course. Class size maximum is 25 students. A reduced student-to-teacher ratio facilitates the establishment of trust between student and faculty.
A course titled Introduction to University provides skills and information required by all beginning postsecondary students. First-term courses include Introduction to Nursing, taught by a nursing faculty member, which is the students’ first encounter with a professional role model in their chosen career path. Students partake in discussions about how the social determinants of health impact North America’s indigenous peoples.
In addition, a science faculty member teaches the Anatomy of the Human Body and Introduction to Biological Diversity courses. The small class size and continuity of the same professor allows for individualized assessment and ease of tracking students’ learning needs. Weekly tutoring (5 hours per week) with the same instructor of the science courses facilitates learning in courses that traditionally created roadblocks to some indigenous students’ success (Orchard et al., 2010).
Biweekly face-to-face meetings with a consistent personal counselor are scheduled. Several factors impede indigenous students’ academic success, including difficulties with time management, finances, family issues, workload organization, child care, and self-confidence (Adams et al., 2005; Cech, Metz, Babcock, & Smith, 2011). Regular counseling sessions facilitate students’ problem-solving and decision-making skills through guidance and support.
In the second term, courses in physiology of the human body, microbiology, and a continuation of biology are taught by the same science instructor. A second nursing faculty member offers instruction in a prerequisite course, Human Growth and Development.
The intent of the ANCI is to facilitate peer support and to provide an academic foundation and necessary remediation to prepare indigenous students for baccalaureate nursing education. Although candidates for the ANCI recognize their needs for personal support, tutoring, and some level of academic accommodation, they do not want to be judged as “less than” other candidates seeking eventual admission to the school of nursing.
Entering into Baccalaureate Nursing Education: The Path Continues
Students who successfully complete two of the three terms of the ANCI with a minimum grade of C in each course are eligible for conditional acceptance into the school of nursing. Pending successful completion of all remaining prerequisites in the third term, including a course offered by the Department of Native Studies, ANCI students may be admitted to the school of nursing. Because many students indicate they want to practice nursing in indigenous communities after graduation, an understanding of how colonialism and neocolonialism impact North America’s indigenous peoples is crucial.
Students with a competitive grade point average may opt to apply to the school of nursing in the regular admission stream. ANCI students with a lower grade point average may choose to apply under a Special Consideration Policy (SCP). The SCP was implemented in acknowledgement that not all applicants have a common secondary education. In particular, applicants from remote communities and the university’s Access Program may be considered for admission under the SCP. This group comprises approximately 5% of admissions into the school of nursing annually. Less weight is given to academic performance, provided minimal entrance requirements are met. SCP applicants complete a supplementary application documenting their need for special consideration for admission. SCP applicants are also required to include three letters of reference that address the applicant’s suitability for nursing.
After ANCI students are admitted to the school of nursing, they remain as a cohort group for their first clinical rotation to ease them into clinical practice and a professional program of study. Typically, ANCI students take four courses, rather than five courses, per academic term. In the second term, ANCI students merge with the remainder of the student body in all classes, laboratory sessions, and clinical practice. ANCI students may be paired with other ANCI students if desired, but not all students take this opportunity. Many students indicate that they have self-confidence to strike out on their own amidst the larger, culturally diverse student population.
The philosophy of all those involved in this educational innovation is one of team approach. Regularly scheduled meetings involving university and nursing administrators, academic advisors, personal counselors, and faculty allow for student-centered teaching, ongoing program evaluation (policies and procedures), and attention to each student’s progress.
Looking Back and Looking Forward
Several informal evaluations were conducted to seek feedback from students and faculty. In general, ANCI students appreciate the cohort approach. One student expressed: “I like being together—it helps.” Students identified that they flourish with and enjoy the opportunities to establish student–teacher relationships. Free tutoring and individual counseling were identified as significant resources that promote academic success and build students’ self-confidence.
Faculty and advisors acknowledged that using the same faculty to teach the science and beginning nursing courses is a positive feature that provides continuity. Factors that continue to affect retention include students’ anxiety levels, low self-confidence, family issues, culture shock, limited child care resources, and inconsistent and inadequate funding, especially in the first year.
Although we celebrated the first baccalaureate nursing graduates of the ANCI in 2012, several issues require attention. Indigenous students share similar issues with other culturally diverse student groups within the nursing student population. However, what sets indigenous students apart as unique is the historical context of indigenous education in North America and its influences on the student–teacher relationship and students’ misgivings about formal education (including those originating from members of their families and home communities). Professional development seminars are warranted to provide faculty with further skills to implement student-centered approaches. Faculty need information about how the history of education and indigenous peoples in North America influences the student–teacher relationship (Martin & Kipling, 2006), and creative strategies are required to build these student-teacher relationships.
We plan to incorporate further input from indigenous leaders, groups, and communities to formally advise the ANCI to ensure culturally relevant pedagogy and curricula (Anonson et al., 2008; Eschiti, 2004; Gregory, McCallum, Grant, & Elias, 2008). Graduates from the ANCI also will be invited to provide advisement. Clinical and community practicums with indigenous groups and communities would bring a broader scope to the ANCI, although 50% to 60% of patients in a local acute-care hospital self-identify as having indigenous ancestry. Community health rotations with indigenous groups will provide all nursing students with experience working with the indigenous culture (Kearsey, 2003; Mundel & Chapman, 2010).
Formal mentorships were noted to be an integral component to indigenous student success (Katz, Smart, & Paul, 2010). A formal mentoring program will facilitate support between beginning and experienced ANCI students. As with other schools of nursing, we will seek faculty members with indigenous ancestry to serve as positive role models and formal mentors for this student group (Gilchrist & Rector, 2007).
A formal evaluation of this educational initiative will affirm or refute our opinions and anecdotal observations of its merits and pitfalls. By evaluating the program in a manner similar to that used by Curran et al. (2008), positive features may be strengthened, and recommendations may be articulated to forge an evidence-based path for success for indigenous students. Curran et al. (2008) noted: “As an evaluative process, Responsive Evaluation seeks opinions from a broad cross-section of people who have a stake in program success” (pp. 13–14). We plan to use Responsive Evaluation to acquire information from students, graduates, employers, indigenous groups, and communities regarding the educational processes and outcomes.
To recruit and retain more indigenous nursing students, an educational initiative was undertaken involving two pathways for indigenous students interested in pursuing baccalaureate nursing education. By establishing a cohort experience in prerequisite and beginning nursing courses, the initiative was enhanced by the continuity of instructors, advisors, and counselors to enable the development of trust and formal mentorships. Tutoring and reduced course loads provide an academic structure for indigenous students to gain success in prerequisite courses to enter into an undergraduate nursing program. Elements from this exciting initiative may inform undergraduate nursing education for indigenous students elsewhere. Further educational research is required to enhance recruitment and retention of indigenous students in nursing education.
- Aboriginal Nurses Association of Canada. (2006). Best practices for the recruitment and retention of Aboriginal people into nursing education and nursing practice. Ottawa, Ontario, Canada: Author.
- Adams, M., Aylward, P., Heyne, N., Hull, C., Misan, G., Taylor, J. & Walker-Jeffreys, M. (2005). Integrated support for Aboriginal tertiary students in health-related courses: The Pika Wiya Learning Centre. Australian Health Review: A Publication of the Australian Hospital Association, 29, 482–488 doi:10.1071/AH050482 [CrossRef] .
- Adelson, N. (2005). The embodiment of inequity: Health disparities in Aboriginal Canada. Canadian Journal of Public Health, 96(Suppl. 2), S45–S61.
- Anonson, J.M., Desjarlais, J., Nixon, J., Whiteman, L. & Bird, A. (2008). Strategies to support recruitment and retention of First Nations youth in baccalaureate nursing programs in Saskatchewan, Canada. Journal of Transcultural Nursing, 19, 274–283 doi:10.1177/1043659608317095 [CrossRef] .
- Arnault-Pelletier, V., Brown, S., Desjarlais, J. & McBeth, B. (2006). Circle of strength. Canadian Nurse, 102(4), 22–26.
- Association of Canadian Community Colleges. (2005). Meeting the needs of Aboriginal learners: An overview of current programs and services, challenges, opportunities and lessons learned. Retrieved from http://www.accc.ca/ftp/pubs/200507_Aboriginal.pdf
- Cech, E.A., Metz, A.M., Babcock, T. & Smith, J.L. (2011). Caring for our own: The role of institutionalized support structures in Native American nursing student success. Journal of Nursing Education, 50, 524–531. doi:10.3928/01484834-20110517-01 [CrossRef]
- Chapman, C., Laird, J. & Kewal Ramani, A. (2010). Trends in high school dropout and completion rates in the United States: 1972–2008. Retrieved from http://nces.ed.gov/pubs2011/2011012.pdf
- Curran, V., Solberg, S., LeFort, S., Fleet, L. & Hollett, A. (2008). A responsive evaluation of an Aboriginal nursing education access program. Nurse Educator, 33, 13–17 doi:10.1097/01.NNE.0000299496.23119.68 [CrossRef] .
- DeLapp, T., Hautman, M.A. & Anderson, M.S. (2008). Recruitment and Retention of Alaska Natives Into Nursing (RRANN). Journal of Nursing Education, 47, 293–297. doi:10.3928/01484834-20080701-06 [CrossRef]
- Eschiti, V.S. (2004). Holistic approach to resolving American Indian/Alaska Native health care disparities. Journal of Holistic Nursing, 22, 201–208. doi:10.1177/0898010104266713 [CrossRef]
- Evans, B.C. (2008). The importance of educational and social backgrounds of diverse students to nursing program success. Journal of Nursing Education, 47, 305–313. doi:10.3928/01484834-20080701-04 [CrossRef]
- Gilchrist, K.L. & Rector, C. (2007). Can you keep them? Strategies to attract and retain nursing students from diverse populations: Best practices in nursing education. Journal of Transcultural Nursing, 18, 277–285. doi:10.1177/1043659607301305 [CrossRef]
- Gilliss, C.L., Powell, D.L. & Carter, B. (2010). Recruiting and retaining a diverse workforce in nursing: From evidence to best practices to policy. Policy, Politics & Nursing Practice, 11, 294–301. doi:10.1177/1527154411398491 [CrossRef]
- Gracey, M. & King, M. (2009). Indigenous health part 1: Determinants and disease patterns. The Lancet, 374, 65–75 doi:10.1016/S0140-6736(09)60914-4 [CrossRef] .
- Gregory, D. & Barsky, J. (2007). Against the odds: An update on Aboriginal nursing in Canada. Ottawa, Ontario, Canada: Canadian Association of Schools of Nursing.
- Gregory, D., McCallum, M.J., Grant, K. & Elias, B. (2008). The Swampy Cree Tribal Council and Aboriginal governance: A case study of nursing education in Northern Manitoba. Canadian Journal of Nursing Research, 40, 132–149.
- Hampton, M. & Roy, J. (2002). Strategies for facilitating success of First Nations students. The Canadian Journal of Higher Education, 32(3), 1–28. Retrieved from http://ojs.library.ubc.ca/index.php/cjhe/article/view/183417/183371
- Health Canada. (2005). Health human resources action plan—Status report. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/pubs/hhrhs/action-plan/index-eng.php
- Health Canada. (2008). First Nations & Inuit health: Health careers. Retrieved from http://www.hc-sc.gc.ca/fniah-spnia/services/career-carriere/index-eng.php
- Katz, J.R. (2005). “If I could do it, they could do it”: A collective case study of Plateau Tribes’ nurses. Journal of American Indian Education, 44(2), 36–51.
- Katz, J.R., Smart, D. & Paul, R.N. (2010). Creating a path: American Indian/Alaska Native high school students pursuing college and a career in nursing. International Journal of Nursing Education Scholarship, 7(1), Article 22. doi:10.2202/1548-923x.1971 [CrossRef]
- Kearsey, K. (2003). Model behaviour: Aboriginal role models encourage Native youth to pursue a career in caring. Registered Nurse Journal, 15(2), 12–16.
- Keohane, S.K. (2009). The Reservation boarding school system in the United States, 1870–1928. Retrieved from http://www.twofrog.com/rezsch.html
- Martin, D.E. & Kipling, A. (2006). Factors shaping aboriginal nursing students’ experiences. Nurse Education Today, 26, 688–696 doi:10.1016/j.nedt.2006.07.013 [CrossRef] .
- McBride, W. & Gregory, D. (2005). Aboriginal health human resources initiatives: Towards the development of a strategic framework. Canadian Journal of Nursing Research, 37(4), 89–94.
- Minority Nurse.com. (2009). Minority nursing statistics. Retrieved from http://www.minoritynurse.com/minority-nursing-statistics
- Mundel, E. & Chapman, G.E. (2010). A decolonizing approach to health promotion in Canada: The case of the urban Aboriginal Community Kitchen Garden Project. Health Promotion International, 25, 166–173 doi:10.1093/heapro/daq016 [CrossRef] .
- National Aboriginal Health Organization. (2006). Strategic framework to increase the participation of First Nations, Inuit and Métis in health careers. Ottawa, Ontario, Canada: Author. Retrieved from http://www.naho.ca/documents/naho/english/pdf/hhr_StrategicFramework.pdf
- Norris, T., Vines, P.L. & Hoeffel, E.M. (2012). The American Indian and Alaska Native population: 2010. U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf
- Orchard, C.A., Didham, P., Jong, C. & Fry, J. (2010). Integrated nursing access program: An approach to prepare Aboriginal students for nursing careers. International Journal of Nursing Education Scholarship, 7(1), Article 10. doi:10.2202/1548-923X.1777 [CrossRef]
- Pijl-Zieber, E. & Hagen, B. (2011). Towards culturally relevant nursing education for Aboriginal students. Nurse Education Today, 31, 595–600. doi:10.1016/j.nedt.2010.10.014 [CrossRef]
- Smith, D., McAlister, S., Tedford Gold, S. & Sullivan-Bentz, M. (2011). Aboriginal recruitment and retention in nursing education: A review of the literature. International Journal of Nursing Education Scholarship, 8(1), 1–22. doi:10.2202/1548-923X.2085 [CrossRef]
- Statistics Canada. (2008, January15). Aboriginal peoples. Retrieved from http://www12.statcan.ca/census-recensement/2006/rt-td/ap-pa-eng.cfm