But whenever Tallbull visited a doctor, she also noticed something she thought was odd. None of the caregivers she saw were Native American women.
"I thought it would be cool to have Indian women in that role," she said. "I thought it was unattainable, and I wanted to do unattainable things."
Tallbull has since bucked the trends she noticed growing up. She enrolled in Montana State University's College of Nursing and is now a nurse on the Northern Cheyenne Indian Reservation in Lame Deer. She is also pursuing a master's degree in nursing, with a clinical nurse leader option, through an online MSU program.
Tallbull is one of 48 nurses who have gone through MSU's Caring For Our Own program, which is changing the face of nursing for Native Americans on reservations and in cities across Montana.
Started in 1999, Caring For Our Own, nicknamed CO-OP, aims to recruit and graduate Native American nurses who will work on Native American reservations or in urban settings in Montana. CO-OP supports bachelor's and master's students with tutoring and advising help. Many students and graduates also say informal support from CO-OP peers and administrators is crucial to their success.
"Our short-term goal is to create opportunities for students to have a university education in nursing," said Kay Chafey, a long-time MSU nursing professor. Chafey, who is not Native American, started the program along with Sara Young, an enrolled member of the Crow tribe, who is now MSU's INBRE director of tribal health and tribal college programs.
"Our long-term goal is to create opportunities for Native American men and women to be successful in nursing," said Chafey, who is now retired. "Ultimately, our focus is on improving the health of Native American people in Montana."
Helen Melland, dean of the College of Nursing, said the program has enjoyed success.
"For more than 10 years, this program has been providing opportunities for our Native American nursing students, who then use their skills and knowledge to improve health care in Montana's Native American communities," Melland said. "It's a wonderful example of a program that is truly making a difference not only for our students, but also for our state."
Addressing critical need
Improving the health of Native Americans in Montana, who are 6.4 percent of the state's population, is critically needed, Chafey said.
In 2006, the median household income of Native Americans living in Montana was $25,696, according to a recent CO-OP grant proposal. For the general Montana population, median household income rose to $44,042, and for people living in the U.S., it was $52,175. In Montana, 52 percent of Native American children lived in poverty in 2006, compared with a 17 percent poverty rate for other Montana children and an 18 percent child poverty rate nationwide.
Health care delivery in rural areas, including reservations, is poor, Chafey said. Barriers to health care include poor roads, geographic isolation and lack of public transportation and reliable telephone service.
"So much of my day is spent dealing with logistics," said Tallbull, who is acting director of nursing at the Northern Cheyenne Service Unit. "I have to track down patients in person or send a message if they don't have telephones. If they don't have cars, I'm looking for ways to get them (to the clinic)."
Another barrier is that people who lack health insurance often depend on Indian Health Service and/or tribal health services, which have been limited due to cuts and a difficulty recruiting and retaining providers on reservations, Chafey said. Even those with health insurance often have limited access to care or are distrustful of it.
Several years ago, Martha Garcia, then a CO-OP nursing student, was working as a student intern on the Crow Reservation in southeastern Montana. A Native American woman was brought into the emergency room, disoriented and distressed, and medical staff members were unable to calm her down. The patient saw Garcia and things began to change.
"We made eye contact, and she reached over, took my hand, and asked me if I was Crow," said Garcia, now a nurse in Lame Deer. "I said, 'no, I'm Pueblo.' The woman immediately calmed down. I think she felt like she would be safe with me. We are the same people.
"I think it comforts Native American patients to see that Natives will be caring for them."
Training Native caregivers has its challenges, too.
Mariya Couch, who is Northern Cheyenne and a current CO-OP student, said that for many Native American students, attending a university is similar to traveling in a foreign country.
"On a reservation, community is important, not individualism. To go from a community where everyone helps you and looks out for you to one that's more individualized and Westernized is truly difficult."
Because Couch grew up in Billings, her experiences at MSU have been different from those of students coming from reservations. Still, she said it would have been "bleak" to be a student without the support of CO-OP.
"CO-OP is a home away from home," Couch said. "(CO-OP staff members) helped me communicate with my professors and brainstorm ways to make things work. They helped me find a childcare scholarship and navigate housing in Bozeman. They can provide students with pretty much anything they ask for."
Origins of support
Chafey observed that many Native American students arrive at the university almost as though they "were at sea."
"For many of these students, coming to school is like someone taking you and plunking you down in the middle of a big city in a foreign country," Chafey said.
"Most of our students are the first in their families to go to college, so they can't ask their parents or other family members for advice," Chafey said.
When Chafey arrived at MSU in 1977 as assistant dean in the College of Nursing, she quickly identified mentoring needs for Native American students, though there wasn't funding to do much formally.
Chafey started small. She took on about 10 Native American nursing students as advisees. She sequenced their schedules so that they took classes they tended to be most successful in first. She worked to arrange a childcare cooperative, so that Native American students helped look after each others' kids when they weren't in class, later working with the ASMSU Day Care to meet CO-OP childcare needs. Chafey said she worked to be open to cultural differences in her interactions with Native American students.
Chafey noticed that students who received even a small amount of help were more successful than those who didn't. In 1996, she and Young, who had been involved in several other MSU programs for Native American students, submitted a grant proposal to the federal government's Health Resources and Services Administration's Division of Nursing to create a formal program to support Native American nursing students. CO-OP received funding in 1999. The CO-OP program now also receives Indian Health Service funding to train Native American students to be family nurse practitioners and clinical nurse leaders through several College of Nursing graduate programs. Young continues to advocate for the program, though her role is now informal.
In more than a decade, CO-OP has expanded into a program that offers advising and tutoring help and also helps students navigate university life and lends emotional support.
"We help students brainstorm solutions to problems," Chafey said. "We talk about ways of preparing for exams. We say, 'Here's what you could do to be successful.' We act like family."
As in families, roles change. Chafey retired from the program in 2009. Melland oversees the program and Twila Old Coyote, who is Crow and Gros Ventre, is the assistant director.
Care in many forms
Billie Brown pulls medications and immunizations from a staff refrigerator in Lame Deer and arranges them on a cart to wheel to the nurse's station. Outside the room, about a dozen patients sit in a stark waiting area, quietly waiting to see one of several doctors at the facility that day. As Brown walks through the wide, coral-hued hallways filled with Native American artwork, she explains how health care is changing to better serve the needs of Native Americans.
Brown, 37, is Gros Ventre and Assiniboine and grew up on the Fort Belknap reservation. She said employing Native American nurses who understand their patients' culture is important.
"Understanding the system helps our patients trust that we understand what they need," she said. "It's so much easier and effective for the (nursing) exchange to occur between Native American patients and a Native American nurse. There is intrinsic acceptance."
Brown was teaching biomedical sciences at Fort Belknap College in 1996 when Young recruited her to be a member of CO-OP's advisory board. Brown later worked at MSU as an academic adviser before deciding to enroll in the program part time. In addition to working in Lame Deer, Brown is now a part-time student in the MSU family nurse practitioner graduate program.
"Listening to other CO-OP students tell their stories allowed me to realize the many opportunities a nurse can have to affect the lives of community members and make positive change on each of our home reservations," Brown said.
Similarly, Tallbull, 37, said CO-OP has helped shape her life and career.
After high school, Tallbull received a bachelor's degree in pre-medicine from MSU and then considered applying to medical school, a lifelong ambition. But after giving birth to a daughter, she changed her mind, instead deciding to work in the emergency room in Lame Deer while taking classes at the tribal college.
Several nurses in Lame Deer convinced Tallbull to pursue a nursing career.
"They said there were lots of opportunities in nursing," Tallbull said. "I changed my mind about going to medical school, but I still wanted to care for others, and nursing fulfilled that goal."
Tallbull enrolled at MSU and said it was evident that people running CO-OP wanted her to succeed. She said gestures that might seem small--such as her adviser buying her a simple day planner--made a huge difference.
"I wrote every single thing in that organizer," Tallbull said. "I had a (young) daughter then, and I needed to spend time with her and do my homework. I planned out every second of my day. I don't think I would have been able to get everything done without writing it down."
The CO-OP experience also gave Tallbull assurance.
"They always stressed how important we were, what kind of a difference we can make (as Native American people)," she said. "This gave me confidence. I know this is where I'm supposed to be."
Now, as acting director of nursing at the Northern Cheyenne Service Unit, Tallbull continues to use a day planner to organize her schedule. And her daughter, who is now 12, aspires to be a nurse someday, too.
That young people like Tallbull's daughter now talk about joining the nursing profession gives Chafey hope for the future of nursing in Native American communities.
"More Native Americans are becoming interested in nursing," Chafey said. "It's a profession they now know they can attain."
CO-OP has faced financial challenges recently. The loss of a grant reduced the amount of financial support available to students and forced the College of Nursing to find other funds to pay staff members' salaries. Still, MSU remains committed to CO-OP, and the program is often cited as one of the university's model programs for Native Americans, Melland said.
"These nurses had a good experience here at MSU. They didn't have to claw their way through, but had support and help," Chafey said. "That makes a huge difference. And now we have lots of ambassadors who credit CO-OP for being a good experience. I think they would recommend the program to others. They would say, 'It's hard, but if you want to do it, you can.'"