Cold Cases: Itinerant Nursing in Southwest Alaska

Peggy Dryden, RN, MSN, MBA, MLS

Disclosures

September 02, 2004

Editor's Note:
Itinerant nursing, or nursing that involves traveling from place to place, is not unusual in public health. Itinerant public health nursing in Alaska, however, is its own unique experience. In this eLetter series, you will discover how unique this position can be as 3 very dedicated, adventurous, hard-working, and independent nurses share their experiences in caring for their patients in southwest Alaska. For a moment, imagine standing in a place where snow-peaked mountains meet the water and the temperature hovers around 50° F during the warmest days of summer as we transport ourselves to Bethel, Alaska to meet Suzanne K. Edelman, RN, BS, MS, APN; Mary Berliner, RN, BSN, PHN; and Jane Conard, RN, BSN, APN. Suzanne, Mary, and Jane are public health nurses (PHNs) employed by the state of Alaska's Public Health Nursing program.

Let's begin with Jane Conard, RN, BSN, APN, a nurse manager. Jane begins our discussion by describing the Alaskan experience and sharing some descriptive and factual information about the organization and the clients these nurses serve.

An Alaskan village.

Before moving to Alaska in 1989, Jane worked in public health nursing in Missouri, where she received her BSN. Jane has since worked as an "itinerant" nurse for many years in Alaska. She is very active in community work in Bethel. She is the mother of 3 adult children.

Question: What population do you serve as a PHN in southwest Alaska?

Response: To begin, I need to explain a little about Bethel and Alaska. Alaska is a large state with a small population. Our office/headquarters is located in Bethel, Alaska, which is 400 miles west of Anchorage and not connected to any road system. PHNs travel primarily by small plane. Bethel is the eighth largest city in Alaska and has the fourth busiest airport, providing passenger and freight services as the regional hub of the Yukon Kuskokwim Delta (YK Delta). Bethel provides governmental services and shopping opportunities to 50 villages spread out over 45,000 square miles and a total population of approximately 25,000 people.

View from the air.

Christine Dittrich, a student nurse from the University of Alaska, Anchorage, traveling by plane.

Almost half of the population we serve lives in the census area of Wade Hampton in southwest Alaska. This area is made up of many forms of city or village governments but without a structured regional administration organization. The population is geographically located in the YK Delta and consists predominately of Alaskan natives, including the central Yupik Eskimo and Athabaskan Indian.

The villages in our service area consist of at least 95% Alaskan natives. The Yupik have a vigorous culture celebrating their tradition and native language. English is a second language in this culture. The community health aides in the clinics translate for us.

Question: Jane, you mentioned that PHNs travel primarily by small plane. What is this travel like?

Response: Traveling as a PHN in Alaska presents several challenges. We travel on 20-seat planes most of the time. Flying by plane to a village when weather conditions are poor, with icy surfaces and intense cold, can be daunting. The PHN will typically carry 8 to10 bags with all the clinical supplies, equipment, food, clothing, and personal items that may be needed. When we arrive in the village, we live in the clinic, which may or may not have running water. (About 40% of clinics still have no plumbing, although this is improving.)

Travel to clinics.

Question: What types of care do PHNs provide?

Response: In a clinic setting, we provide a wide variety of health assessment, health promotion, and disease prevention services. In addition, we offer program management services in the area of infectious disease, family and individual health, violence and injury, health data assessment, and community health.

Question: Could you describe the public health organization in Alaska? How is it structured?

Response: As state employees, PHNs are members of the Executive Branch of state government. The governor, as chief executive officer of Alaska, directs the executive office of the state, which serves as a liaison between the state and federal governments, and among the legislative, judicial, and executive branches of state government. To accomplish the goals the governor sets forth, there are 14 departments each headed by a Commissioner. Public health nursing is located under the Health and Social Services Department. Health and Social Services is further divided into divisions and boards.

The Division of Public Health is divided into 6 sections, including the Section of Public Health Nursing. Public health nursing is then divided into geographic regions that are overseen by a Regional Nursing Manager. The regional management is further divided into nurse managers and team leaders in remote sites. Overall, services in Alaska are provided through a network of 2 administrative offices, 4 regional offices, 20 public health centers, and itinerant services to 250 communities across 586,412 square miles.

Suzanne, an advanced practice nurse (APN), provides many primary care services, primarily in the areas of women's health and screening for sexually transmitted diseases (STDs).

Suzanne K. Edelman RN, BS, MS, APN, came to Alaska (for a second time) in 1999 from Idaho, which she states was a low paying state for nurse practitioners. "Within 2 years, I tripled my 1998 salary!" Suzanne started her career in nursing with a BS and Master's degree from Idaho State University. She acquired nurse practitioner certification from UCLA Harborview in Torrance, California. She has spent 15 years as a psychiatric nurse clinician and 17 years in community and public health nursing in South Dakota, Alaska, and Idaho. This includes 7 years in reproductive health as an APN.

Question: Suzanne, please tell us about your position on the public health team.

Response: My current position in Bethel, Alaska as an APN provides support to the itinerant PHNs in the villages. These nurses provide the public health services including immunizations, child health screening, and communicable disease prevention and control in the YK Delta. Every other week I work in reproductive healthcare in the Bethel Health Center.

Both in Bethel at the Health Center and in the villages, I screen teenagers, men, and women for STDs, provide birth control, perform Pap tests, discuss fertility issues, and provide general women's healthcare screenings. My work includes providing education presentations to schools, correctional facilities, and community groups concerning matters of sexual health.

Question: Can you describe what a trip to a village clinic is like?

Response: When I am in the villages, I typically "camp out" for 1 to 2 nights, sometimes sleeping on an exam table. I bring my own supplies including tables, speculums, wet mount materials, gowns, paperwork, charting items, health education materials, and any food or bedding I might need. During winter months, that would include several layers of clothes.

Before I arrive at the clinic, the patients are called by the village secretary or "health aide." I see up to 20 patients a day in the clinic with few breaks. Sometimes I am the only professional healthcare provider patients have seen for a number of years. Consequently, after gathering a general history, which includes questions that identify risk behaviors, family size, environmental situations, social settings, in an interview that can often take up to an hour, I can usually identify the most important reasons why they have come to the clinic.

The clinic interview is the most interesting part of my job. I enjoy the stories of the villagers. For instance, I may hear the story of how a young Eskimo woman struggles with school while she is living in a 1- or 2-bedroom house with 12 other people. Her family survives on subsistence. (Each Yupik citizen eats up to 200 pounds of salmon a year, with dried salmon being the only food available during parts of the year.) Her family may participate in other forms of subsistence living including hunting caribou, berry picking (picking up to five 5-gallon buckets a season), preparing tundra greens, seal hunting, wild bird egg gathering, and bird hunting. During the summer, the village families camp out at fish camps, sometimes fishing up to 24 hours without rest. This young woman explains how she and the other village women spend long hours cutting and drying the fish. Her story reveals why she struggles to keep up with school work.

Question: What kinds of healthcare issues or problems are common in the settings you visit?

Response: Birth control is an issue. The use of birth control is viewed with skepticism. Unplanned pregnancies are very common. Families often deal with teen pregnancies as well. Families may adopt the teen's baby; this is a more widespread response here than anywhere else I have worked. We struggle with this issue. While women seem to value what the healthcare workers have to say about the reasons for the birth control failure and are willing to return to see me in the clinic, they often have not used the last birth control method I prescribed for them.

The health aides are vital in caring for the villagers. The health aide communicates the patient's primary healthcare need. The health aides in the villages are key in helping the patients maintain compliance with the prescribed birth control. These aides are also supported by radio, phone service, telemedicine, and emails in the effort to deliver basic health interventions. Public health nursing supplements the village basic operations.

Judy Fancyboy, a health aide, and her family.

Question: What other health issues affect the village women you see?

Response: Sexually transmitted infections are a huge problem. Alaska is number one in the nation for incidence of Chlamydia infections, and the delta area has the highest incidence in the state.

The village women are also at risk for alcohol-related problems and predatory sexual crimes. Because women often leave their small, alcohol-free, close knit, religious villages to come to the hub town of Bethel or urban Anchorage for a college or trade school education, they may be naive and suffer health-related consequences as a result.

Many of the women who come to their appointments arrive on snow machines or 4-wheelers. It will sometimes take them up to 1-2 hours to get to their appointment because of the weather. It is not uncommon to examine a woman who has brown scars on her skin that are related to hypothermia, frostbite, or some untreated common skin disorder. The middle-aged village women have often had up to 10 pregnancies. Most of their families have histories of losses, including early accidental deaths and suicides.

Finally, we talked with Mary Berliner, RN, BSN, PHN, a PHN for the State of Alaska. Before receiving her nursing degree in Cincinnati, Ohio at age 35 years, Mary was a "stay at home Mom," raising 3 children. After graduating with her BSN in 1992, Mary worked in various settings, including a nursing home, a homeless clinic, and a large hospital in Cincinnati. (Her oldest son has since graduated from West Point and just returned from a 7-month tour in Iraq.)

Mary Berliner, in Hooper Bay, Alaska.

Question: Mary, what brought you to your current position as an Alaska PHN?

Response: After working for several years as a PHN in the lower 48 states, I was ready for a change. I was interested in working with the Native American population. I began my nursing career in Alaska working as a Pediatric Case Manager. It was in Alaska that I realized I wanted to be a PHN.

Eighteen months after meeting with a PHN Regional Nurse Manager, I entered my first position in public health as a clinic nurse. In this position, I was responsible for providing immunizations, well child exams, screening for STDs, 2-week newborn home visits, and tuberculosis (TB) investigation and case management. After serving as a PHN III for 3 1/2 years and with extensive training, I became a generalist itinerant (traveling) PHN, and I have been in this job for the last 4 1/2 years.

The position includes providing well child screenings, administering the Denver Developmental Screening examination, providing immunizations, offering screening and counseling for STDs including HIV, assisting in or providing women's health exams, providing prenatal visits, providing bioterrorism information, and communicable disease investigation and management.

Question: What is your working schedule like?

Response: Every other week, I travel to 5 remote villages on the Yukon and Kuskokwim rivers. I stay 5 days in one village. While I am in the village, the clinic is my home. I sleep, eat, and see clients in the clinic! I also provide home visits and some educational presentations for the villagers. In preparation for the trip, I make lists of clients to be seen, prioritizing by infants, children under 5 years, pregnant mothers, people requiring immunizations, etc. This priority list is faxed to the clinic ahead of time. I pack all my supplies, vaccines, and personal items including food. I work independently in planning my schedule and travels.

I commute to the villages via small aircraft, or sometimes by small boat, snow machine, or hovercraft. Upon arrival, the airline agent helps me carry my supplies. We then travel to the clinic by pickup, snow machine with sled, or 4-wheeler.

Question: What is your typical day like?

Response: At the clinic, I meet with the community health aides to receive an update on what's going on in the community. I set up the exam room with my supplies (some exam rooms are kitchens or just closets). I then begin seeing clients. A usual day in clinic consists of well child exams, immunizations, Head Start screenings, women's health (Pap tests and clinical breast exams), prenatal exams, STD and HIV screenings and counseling, and possibly some TB case management and/or an educational presentation. All of this work makes for very long 12- to 14-hour days. In addition, if there is an emergency, the health aides may need my assistance, requiring that I be up all night awaiting a Medivac evacuation.

Question: How would you describe the facilities and the clinics in which you work?

Response: The facilities vary from village to village. Some of the sleeping quarters, for example, are private bedrooms with bunk beds, while others offer a sofa in the waiting room, an exam table, or the floor to sleep on. The noises one encounters vary also. There is in one clinic, for instance, with a furnace in the waiting room next to the sofa used for sleeping; the furnace sounds like a jet engine taking off every half hour!

The bathroom facilities are most often a challenge. Some clinics do not have running water (or, if they do, the pipes frequently freeze in winter). Consequently, a "honey bucket" is used as a toilet. A "honey bucket" is a 5-gallon plastic bucket with a plastic bag liner and a pinch of Lysol thrown in for good measure. More often than not, water is hauled from either a river or from rain stored in a 30-gallon "clean" garbage can with the lid kept on.

Needless to say, bathing and eating can be a challenge. I've personally bathed out of a cereal bowl-sized container. Most clinics have microwave ovens, making cooking easier. However, sometimes the electricity or the heat fails. Fortunately, I have sometimes been invited by the health aides to their homes to eat. The aides also bring me food to eat at the clinic. I have feasted on such delicacies as smoked salmon strips, swan soup, caribou, moose, bear, beaver or fish stews or soups, whitefish and seal oil, seal meat, duck, ptarmigan, fry bread, and Agutaq' (Eskimo ice-cream) made of Crisco, sugar, and fresh picked tundra berries ((blueberries, salmonberries, and blackberries) all hand-whipped together.

A typical health clinic.

Question: How would you describe the villages that you visit?

Response: Some villages are in beautiful mountain scenic areas with trees along the river. Others are on the flat, treeless tundra. All the villages have dirt roads that are muddy in the spring, or dry and dusty in summer, and none of the roads lead out of the village. The villagers travel between villages by boat in summer and snow machine in winter. Traveling can be very difficult and dangerous, and weather delays are frequent. On occasion, I am "weathered-in" at a village for an entire weekend. Traveling at -40° F through blowing snow is a hardship. The villagers, however, are the most generous people, often offering nurses their last bit of food or the coat off their backs. They are full of laughter and have a very loving nature, especially toward children.

The adults love to perform native dances and take long hot steam baths. I have been invited "to steam," and it is quite a ritual, and very hot! The women typically will take a steam together and talk about "women" things. The men steam together and try to see who can stand the hottest temperature.

Question: What has been your most rewarding experience?

Response: My most rewarding and demanding experience occurred in February of 2003 and involved a woman from one of the upriver villages who became reinfected with TB. She was unaware that she had TB for quite awhile, so she had been out in the village coughing, visiting others, and generally spreading the infection to many other people.

After she was diagnosed, I initiated the contact investigation that turned up several new latent TB infections and a few active TB cases. As a result of the number of new cases, I took 2 new PHNs to the area to do a TB sweep. I gathered donated gifts from local agencies to give away as door prizes. (I learned very quickly that if you want people to participate, you need to give door prizes and have food!) We packed up all our TB supplies including syringes, purified protein derivative (PPD) for skin testing, sputa collection tubes, alcohol wipes, cottontails, etc. and headed north via aircraft. Our objective was to administer TB skin tests or obtain specimens from all those villagers with a history of previous TB infection.

After setting up base camp at the clinic, we went house to house, to stores, the bingo hall, all 3 schools, and the preschool -- anywhere we could think of to get people tested. We announced our objective over the very high frequency radio from the clinic and proceeded to test as many people as we could over the next 5 days.

On a day when I was going house to house placing TB skin tests and offering flu shots, I encountered a man skinning a gigantic moose leg. I very carefully placed his TB skin test on his forearm while he continued skinning the moose leg. His wife and another woman were sitting on the floor on large pieces of cardboard using their ulu knives to carefully cut the meat into pieces for cooking, while a baby crawled nearby. (Ulu knives are handmade of steel in the shape if a crescent moon, with a very sharp outer edge and a wood or bone handle attached to the dull side of the blade. The ulu knife is excellent for cutting any meats or cutting salmon for drying.) His wife requested a flu shot, so without hesitation I climbed over the moose leg, the crawling baby, and the meat on the cardboard to administer her skin test and flu shot. All in a day's work!

We ended up testing about 75% of the people in the village and found a few more cases. I later returned to do 3 more TB sweeps (with 2 nurses from the Department of Epidemiology in Anchorage) of the village over the span of a year. Altogether there were 23 TB cases to manage, 10 of which were active cases and needed to have directly observed therapy. This required hiring an individual to watch the client take their TB meds for 6 months. I found a reputable individual and signed him up. Within 6 weeks, he, too, had active TB, so I had to find someone to take his place. As of this writing, there are only 2 individuals in this village who are still on medication. There have been no new cases found during the last sweep 3 months ago; however, the monitoring continues. This project has been quite a challenge. Nonetheless, I'm grateful for the training I received from the state that give me the confidence to handle the situation.

Question: Do you have any recommendations for readers considering this type of position?

Response: For any nurse considering this type of work, I recommend they are flexible, able to think for themselves, desire professional autonomy, have upper body strength to carry all those bags, and have a great sense of humor. The rewards of this job are too numerous to count.

Anyone who is interested in finding out more about the field of itinerant public health nursing in Alaska should contact the PHN program directly.

Thanks to all our contributors -- Jane, Suzanne, and Mary -- for sharing their stories. Readers may contact Jane Conard at jane_conard@health.state.ak.us, Suzanne Edelman at suzanneedelman@yahoo.com, and Mary Berliner at marebear65@hotmail.com.

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