How a small Navajo hospital is delivering care amid a big nursing shortage
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Johanna Bahe is running late. The longtime nursing supervisor is striding down a hall at the Indian Health Service (IHS) hospital in Chinle, Ariz., her familiar outline in teal scrubs setting a double-time pace. The staff briefing about an impending flu surge lasted through lunch, and now Bahe is fielding a call from a rattled employee. “It’s broken?” She frowns, resting her face against her phone. A surprise windstorm that swept through their Navajo reservation damaged a canopy that covers drive-thru respiratory services. They’ll need to reroute patients.
Bahe stops near the hospital entrance, a sunny room bordered with the kind of geometrical designs you see woven into Navajo rugs. As she counsels her caller, Bahe gestures toward a bank of transaction windows a few yards away. “Our pharmacy,” the Chinle native explains, adding that their patients can’t pick up medications at a Walgreens or Walmart, because there aren’t any. Such is life on a reservation.
Most nursing supervisors don’t deal with pharmacy deserts and surprise windstorms. Bahe gets that. Behind the stylish eyeglasses is a woman who’s spent nearly 30 years with the IHS, a woman who is comfortable in her niche. But if there is a leveler in her field these days, it’s stress. Heavy workloads for nursing supervisors are par for the course nationwide, and the strands of gray winding through Bahe’s head of jet black hair may be proof of it. But she also has another problem on her hands—a 50 percent staff vacancy rate. A nursing shortage threatens hospitals across the nation, but in Navajo country, the crisis is especially acute.
WARS AND ECONOMIC RECESSIONS have caused nursing shortages in the United States before, but none with the Richter scale reading of the current crisis. To turn the tide, experts say more than 1 million new registered nurses (RNs) must don scrubs by the end of the decade. COVID-19 could be the culprit—with its front-line exhaustion, burnout, and vaccination requirements—but an aging population of both patients and nurses is also to blame. With a fifth of the nation’s RNs ready to retire and the need for health services at an all-time high, a shortage was percolating long before the exodus-inducing pandemic.
At 52, Bahe is the median age of America’s RNs. The married mother of four is proudly Navajo, from casual mentions of her “clan” to the colorful jewelry she wears. “I learned beadwork from my grandmother,” she explains, fingering the edge of an earring. One heritage Bahe would like to shirk, however, is the inability of reservation hospitals to recruit and retain nurses. She says it’s always been an issue.
The IHS established a network of clinics to serve American Indian/Alaska Native tribes in 1955, the same year Rosa Parks refused to surrender her bus seat to a white man, launching the civil rights movement. Both efforts required time to make gains. On reservations, measures of success included better sanitation programs, higher immunization rates, and expanded use of antibiotics. Today, some hail the IHS as one federal program that has worked, pointing to feats like an 82 percent decline in the infant mortality rate. Despite a nearly $7 billion budget, though, staffing shortages plague IHS facilities. Most explanations involve the old real estate adage—location, location, location.
The Navajo Nation, sprawling across the upper northeast corner of Arizona and into parts of New Mexico and Utah, is the largest Indian reservation in the United States. It’s the size of West Virginia. Chinle, with its 60-bed hospital, sits at the center of a canvas painted in a palette of browns and beiges. The facility combines with others on the reservation to meet the medical needs of more than 244,000 Navajo, some living in areas without electricity and running water. Bahe says a lack of services can affect outcomes when patients go home. Wound care requires water. Some medicines require refrigeration.
Still, Chinle does have at least one major attraction—beautiful Canyon de Chelly, a geological wonder that attracts tourists, hikers—and sometimes, nurses.
Lorraine Begaye heads up staff recruitment at the Chinle hospital. She uses photos of the canyon to advertise nursing positions on social media, but it’s a hard sell even with beautiful images of sandstone-walled gorges and wild horses roaming free. Chinle’s isolation either attracts or repels. There’s little shopping in town, and only a Denny’s and a Subway on the main drag. No theater. The closest city is 90 miles away.
Those challenges seem minor compared with what Begaye is dealing with today. The spouse of a new nurse is having a hard time getting a job on the reservation because he’s not Navajo, and he wants the family to leave. “We have the Indian preference, the Navajo preference, in all the jobs here,” explains Begaye. Another employee is thinking of quitting because of the reservation’s school system. “They want certain things for their children at a certain level, things Chinle’s schools can’t offer.”
But two of Chinle’s nurses are happy to list its advantages. Brandy Stone wanted to experience Native American culture, and she’s a big fan of yoga classes conducted on one of the scenic rims of the canyon. Michelle Kendrick first came to Chinle as a travel nurse during the pandemic. She returned seeking permanent placement because she likes the slower pace and the idea of federal retirement. Like all onboarding newcomers, Stone and Kendrick watched IHS-produced videos to help with their transition to reservation life. They learned to avoid direct eye contact, for example, to enter rooms in a clockwise fashion, and refer to the elderly as “grandmas” and “grandpas.” It’s traditional Navajo etiquette, which goes a long way in facilitating nurse-patient relations.
In Chinle, travelers fill about half the slots, underscoring what’s becoming apparent not just on reservations but nationwide—staff contracting is big business. AMN Healthcare, a top pool of traveling healthcare professionals, has in recent years tripled its pre-pandemic profits. Even now, with the urgent need to fill vacancies subsiding somewhat, travel nurses doing stints in California can make more than $4,000 a week. Regular staff nurses aren’t doing too badly at large facilities, either. The shortage has Billings Clinic in Montana offering its nurses $600 to pull an extra shift, and that’s in addition to $45/hour overtime pay.
A chance to make $1,140 for a 12-hour shift? That’s a boon for nurses, but a bust for small, rural hospitals. High wages aren’t a financially sustainable solution to their nursing shortages. According to the Center for Healthcare Quality and Payment Reform, more than 100 rural hospitals have closed in the past decade, and another 600—nearly a third of all rural hospitals in the country—are on the brink.
While most reservation hospitals are rural, they have federal support to keep them afloat. Bahe says that allows Chinle to sweeten its nursing appeals with recruitment and retention incentives as high as 25 percent of a new hire’s salary. They also pay relocation expenses, and a majority of applicants qualify for the student loan repayment program. That’s a lot of enticement, but at Chinle, there’s something else—on-site IHS housing. Just behind the hospital, one-bedroom apartments rent for about $360 a month. A three-bedroom home like Bahe’s is just $240 more. She can walk to work across the dusty landscape in eight minutes flat.
But even with all the bonuses, staff vacancies persist. Bahe admits she recently had to pull a shift in the hospital’s maternity ward, something that wouldn’t happen in most hospitals. Here, however, permanent staff are cross-trained to fill in gaps. Shortages mean they work extended hours and cover multiple departments. That can lead to burnout, which puts the squeeze on schedulers.
CHINLE ISN’T ALONE IN ITS WOES. Nurse Laura Plumb spent three years at the IHS hospital in Gallup, N.M., a reservation border city once known as “Drunk Town, USA.” Although the Navajo Nation prohibits the sale of alcohol, abuse is a big problem. Plumb says it affects the hospital’s ability to retain nurses: “While I was there, travel nurses made up 85 percent of the nursing staff, and most came to earn top wages and leave as quickly as possible.” Plumb is a Christian who wanted to serve in a critical-need area. Gallup’s four-story hospital is as old and sparse as the scrubby sagebrush in the area surrounding it. Resources are limited. “We had to get creative and kind of MacGyver our way through situations,” she remembers.
One night a hatcheting victim, bleeding profusely, arrived in the emergency room. “Usually you have a standard tourniquet to apply, but we didn’t have that on hand.” The team managed to stop the bleeding with strips of a sheet, and doctors followed up with a blood transfusion. “He was fine,” Plumb recalls, but she admits working in Gallup could be overwhelming. “We live in a fallen world, and sometimes the choices people make end up in tragedy. I just had to turn it over to the Lord.”
At Chinle, traditional Navajo religion is on prominent display. An eight-sided log structure known as a hogan stands outside a wing of the hospital, and five IHS-employed medicine men use it during healing ceremonies. On-staff healers may turn off some nursing applicants, but not those who’ve grown up Navajo. It’s one reason the IHS likes to hire Natives. But American Indians account for less than 0.5 percent of RNs across the nation. “Even as a child I noticed all of the nurses were Anglo,” Bahe remembers. “It’s a factor that drove me into nursing.”
Her road to RN was difficult. At first, Bahe moved to Flagstaff, Ariz., to attend school, leaving her young family behind. Then she made daily commutes along a barren stretch of New Mexico’s State Highway 264 to Gallup. She says navigating life off the reservation wasn’t easy, because it’s so different. “We are such a minority, and we’re just not used to the environment. I think that’s one reason many Navajo students don’t succeed in higher education.”
But Bahe’s background wasn’t typical. Her father was a physician’s assistant, one of the first Navajo to earn that degree. Then, unlike so many others around him, he beat an addiction to alcohol. That enabled him to gain custody of his children, and they spent some of their school years off the reservation.
Three of Bahe’s children also graduated from high schools located hours away from Chinle. Neither they nor Bahe’s siblings returned to live on the reservation. She, however, is committed to staying, at least for now. Bahe sometimes says she’d like to live in a place where she didn’t have to worry about certain things—cows, for example. Her 100-head herd was passed down from her father, and a grandfather before him. To give them up, Bahe says, would be irresponsible. Her inheritance grazes in a remote area of the reservation with no access to running water. The nursing supervisor, who holds a doctorate, has to haul it in.
That’s surprising, but no more than Bahe’s account of building a new home in Chinle. She and her husband had to mix and pour the concrete foundation themselves. “We don’t have those kinds of companies here,” she says. Bahe seems resigned to such challenges, and she expects her nurses to be resigned, too. Maybe even more than just resigned. “If they’re not happy here, it’s going to impact patient care. And that’s my big thing. If you don’t want to be here, then this is not the place for you.”
But sometimes acclimation isn’t enough. Tasheena Talayumptewa came to the Chinle hospital as a surgical tech, then went back to school when Bahe and others encouraged her to pursue her nursing degree. Now she has her license but can’t work as an RN until she makes it though federal hiring hoops. It’s a slow process. One snag is a federal security clearance, which can take weeks, even months. “It’s the most frustrating part of recruiting,” Bahe admits. “An applicant is like, ‘Well, I haven’t been working for the last month, and you guys aren’t getting back to me, but another hospital is willing to start me next week.’ So we lose them.”
It’s serious enough to lead Bahe to cite federal delays—not isolation—as Chinle’s biggest staffing hindrance, something she’s been vocal about at the national level. “There’s so many other priorities that this keeps getting lost. It’s the big white elephant in the room that nobody wants to talk about.”
Until they do, Bahe is coming up with her own solutions to the nursing shortage. One is Chinle’s patient transport program. Using an emergency hiring option, Bahe enlists paramedics to intubate, help with chest tubes, put in IVs, and give injections. “That keeps me from pulling a nurse off the floor,” she explains. That’s the kind of ingenuity Bahe thinks nursing supervisors both inside and outside the IHS may need if shortages worsen nationally, as predicted. “Everybody is feeling what we have felt for a long time, but we may be better prepared to cope with it. Living on a reservation has always meant limited resources, whether it’s food, money, water.”
Or nurses. “Whatever it is, we have to figure it out. That’s the kind of mentality we have.”
Less than an hour after the windstorm, three of Bahe’s nurses have successfully rerouted patients from the damaged drive-thru clinic. They’re inside, forming a quiet line in a corner of the ER. When Bahe cruises through, she takes in the scene, evaluating the transition and the flow.
“Yes,” she says, her dark eyes crinkling with a smile. “They figured it out.”
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