Nurses working with Alaska Natives on the continent’s icy frontier are helping to redefine rural health care.
In a 50-bed hospital in Bethel, where doctors treat a population of about 28,000 people—most of them Native Alaskans from nearby villages—nurses provide critical services in a remote location where medical emergencies can be catastrophic. The hospital, Yukon-Kuskokwim Health Corporation, employs a staff of Native nurses who pull double duty as care-givers and cultural interpreters for a team of non-Native doctors.
“We’re looking for those unspoken cues,” said Juanita Treat, a patient advocate with nearly half a century of experience in health care. “We tell doctors not to just listen, but to look.”
Treat, who is Yup’ik, represents a vital link between patients and doctors in this 58,000-square-mile region that is the traditional home of the Yup’ik, Cup’ik and Athabascan people. Although 82 percent of patients are Native, all of the doctors are transplants from the lower 48. That means doctors can miss much of the nonverbal cues and cultural nuances, Treat said.
“We tell doctors that if something hurts, the patients are not going to say so,” Treat said. “Look at their face. They will squint their eyes or flinch. They’ll answer with raising their eyebrows for yes or shaking their head for no. If you’re concentrating on putting answers in the computer, you’re not going to see the silent language.”
These unspoken signals also manifest in ancient traditions, Treat said. Yup’ik patients sometimes present with pieces of red yarn wrapped around different parts of their bodies. To the untrained eye, it’s just yarn, she said. But interpreters know that it’s part of a complicated set of cultural rituals.
“If they have a cut and it looks like it’s getting infected, they’ll put a piece of red yarn above it, and that’s to stop the infection from spreading,” Treat said. “If they have lost a husband, women will come in with red yarn around their waists and around both ankles. They will wear that for a year.”
Treat is part of a team of nurse-interpreters who sit with patients as they interface with doctors and translate language and silent cues. Her services are helping break down a wall between doctors and patients. That’s especially important in a place like Bethel where medical providers stay, on average, only a couple of years before moving to one of Alaska’s urban areas or back to the lower 48.
Courtesy Rebecca Coupchiak
A student nurse sterilizes a patient’s arm before a procedure.
Nurse-interpreters like Treat provide consistency to patients and are part of a solution to the “revolving door” of medical professionals in rural communities. Her duties also include explaining diagnoses in ways patients will understand. Sometimes, Treat said, that involves rewriting the medical dictionary.
“We used to have lots of misinterpretation,” she said. “Doctors use a lot of Latin terms, and those were not translated correctly.”
For example, the Yup’ik term for cancer meant “sore that never heals,” Treat said. So diagnosing a person with cancer meant giving them a death sentence.
“We really needed to be able to sit down with people and explain what these things are,” she said. “When they understand what it is, that it doesn’t mean death, we can encourage them to get help.”
Although nurse-interpreters often are members of the communities they serve, they also receive intense training in a program at the University of Alaska. The university offers an associate of applied science degree in nursing, via distance education. Students can earn degrees from home in Dillingham, Bethel or Nome—all isolated areas on the Alaska frontier.
Each campus also has a local professor who acts as a mentor, and the program requires students to do clinical work at their community hospitals, said Rebecca Coupchiak, assistant professor of nursing at the Dillingham campus. The small campus programs have each graduated tiny classes of only a few students each, but all graduates have found jobs in their communities and many continue their studies and become registered nurses.
“The majority of my students are Alaska Natives who are already entrenched in their culture,” Coupchiak said. “They want to stay in their communities and raise their families here.”
While medical professionals train students for the clinical aspects of their jobs, cultural experts help them hone their skills as interpreters. Coupchiak said success as a cultural interpreter comes when nurses embrace their own knowledge and experiences.
“This culture is theirs,” she said. “It’s important to understand that nurses’ primary goal is to take care of people, but people come from all walks of life. You can get a lot more information about a patient if you understand where they’re coming from, the subtle cues, their culture. Nurses have to be aware in order to provide the best care.”
Courtesy Rebecca Coupchiak
A nursing student practices inserting an IV into an arm.
When it works, nurses form lifelong bonds with patients and provide an essential link in their health care, said Joclyn Reamey, a Yup’ik nurse and interpreter at Bristol Bay Hospital in Dillingham. Reamey, a recent graduate of the nursing program, has only worked for one year, but she has already developed a certain camaraderie with patients that even the doctors lack, she said.
In fact, Reamey said, her patients know her best by her Yup’ik name, Qiivvralria.
“It all started when I was doing my clinical training,” she said. “We’d go into a room and I wouldn’t know who my patients were, just looking at their charts. I wouldn’t recognize their names. But when I went in and saw their faces, I’d know who they were. I knew them better by their Yup’ik names, and they knew me.”