Pioneer Nurse Practitioner
By Lisa Legge
On a recent autumn day, mothers stream through the neat, curved hallways of the Ne-ia-shing Clinic in rural Onamia with their children. Some wheeze with allergies, some ache with colds and flu. The nurse practitioner dispenses practical advice and medications. The young patients make their routine stop at the treat drawer as the visit ends. But one by one as the small groups leave, the mothers call out the same thing.
"Thanks, Gert."
Such is life in the small town primary care clinic of family nurse practitioner Gert Lambert. The final, friendly call from parents — thanks, Gert — illustrates the familiarity and trust she has fostered over the years with the people of the sprawling Mille Lacs Band of Ojibwe reservation. Her professional but laid back style, together with the fact that she alone has provided constant health care for residents here when others have come and gone over 26 years, has made her an indispensable and trusted figure.
"She is a fixture here," said Roberta Davis of Onamia. She met Lambert when her children were babies, in the late 1960s, and comes to the clinic now for help with her arthritis.
Lambert, 57, is arguably the most well established, independently practicing nurse practitioner in Minnesota. She provides the kind of quality, low-cost care communities across the state are seeking and the kind of practice more nurses are considering. She has served as a role model for a number of nurses in her career.
"I wish I could send everyone there," said Pat Eid, MPH, NP-C, an assistant professor at the College of St. Catherine in St. Paul. She coordinates her college's portion of the state's Rural Nurse Practitioner Project, which helps rural nurses get advanced degrees. She has sent several students to Ne-ia-shing.
"Students who have worked with her really appreciate her calm nature, but also her wisdom," Eid says. "Over time she has just gotten so wise about people and how to handle them. That's what you get there: You don't get just how to deal with differential unabdominal pain."
Lambert is the mainstay of the clinic. Five local physicians, three physician assistants and nurse practitioner Mike French rotate into the clinic part-time each week. LPNs Rita Nayquonabe and Victoria Verkennes are there full time.
Until two casinos brought an influx of new people, Lambert says, she had been in every home and knew most everyone on the reservation by name.
SUBHEAD: A Slow Beginning
Gert Lambert worked her way into the community's culture slowly. She began with the children, working half-time as the area's Head Start program nurse in 1970. She added one half-day per week in an office, when a physician was in. That soon became two half days a week. A nursing instructor with a master's degree, she also taught part-time at St. Cloud.
Things soon picked up. She became tribal public health nurse in 1973, then returned to school in the four-month Adult Nurse Practitioner Certificate Program of the University of Minnesota School of Public Health.
But just as her familiarity with patients grew slowly, so it took time to build her practice. Her first three months as public health nurse were lonely.
"I did not push my way into anything," she said. "I did not make a home visit until I was invited to come out. I could see things that were needed, but I made no effort to go out until I was asked. When that invitation came — to come and see a sick child — I went, and word went out about what I could do."
Her most important piece of advice for prospective nurse practitioners is this: Be patient. Don't push your plan of care onto patients.
Lambert demonstrates that philosophy, waiting for cues from her clients about their needs, which she explains is especially important in rural areas.
"If the rural area has been established for a period of time already, the people are going to have a good idea of what health people can do for them," she says. "They're going to present what help they would like from you. They may not say it verbally; you may have to pick up cues and feel them out a little."
She employs the sage nursing technique of gathering information other than what the patient originally intended. "They come in for one reason but you can gradually move into other avenues of the health care, become familiar with the family, what the other health needs are in the family," she said. "But it takes a long time."
Elizabeth Kosiba, RN, CNS, GNP, worked under Lambert's mentorship last spring before graduating from the University of Minnesota's nurse practitioner program in Minneapolis. She said Lambert never tried to teach her about Native American culture, which was fairly new to Kosiba.
"She just let me observe," Kosiba said. With patients, "she takes time and is very respectful.... She doesn't pressure at all, but she does very gently invite the medical care."
Lambert mixes old-fashioned aspects of health care with a highly modern practice, making house calls when necessary and when she is available. She also involves herself in the community, regularly lunching with the older members of the community at the area's Elderly Nutrition Program, attending funerals.
"I try to know what's going on in the community and encourage participation," she said.
Community Goals First
Lambert advises that anyone wishing to start a practice — if they really want to serve the people — put aside their own goals for those of the community.
"If people don't come in with preconceived notions of what they can do for the community, but instead are willing to sit back and take in cues of what some of the needs are and to expand from that, it will work out so much better," she said. "Both will be happier.
"One of the problems some of the providers have had is thinking, 'Well, this is what this area needs.' And then because things don't change that rapidly they get frustrated. I say, 'Just wait. Just wait. Give them a little time and they will come.' "
That kind of patience is key to her staying power. She has weathered many political storms, as people in authority often encounter. She also has managed to keep her faith while serving an area with relatively high poverty and feelings of helplessness.
Although she sees poverty levels changing now with the coming of casino revenue, she still sees a broad array of health problems.
"We have a fairly large number of people with chronic illness — diabetes, hypertension — so I see a lot of folks with those problems. We have real problems with depression. We have alcohol-related problems, things of that nature. Social problems that have somatic symptoms to them. They're in for checking that out, but you find they have other things going on; we work through that or refer them."
Lambert's length of experience at Ne-ia-shing has made her an insightful care provider. "You get to know these things and you can ask them, 'How come you tripped going down the porch this morning?' "
"Her endurance has been phenomenal," Eid says. "She looks past things and that allows her to endure things. That enables her to endure difficulties in not seeing changes in [patients'] lives."
Not surprisingly, Lambert is more humble in explaining her longevity.
"The thing that made it easiest for me was that there was a tremendous turnover of physicians and I was the only person that 90 percent of the people knew. So there was continuity. I could talk to providers who came and give them background information and would help them out. So it was ideal for me. There was a niche that continued to develop and I was able to fill it."
"The system has changed so much, but having been here so long I've just been able to adapt to it," she said. "Nurse practitioners have made a real role for themselves in health care. The public recognizes it and appreciates the services. The public is asking for it and physicians are asking for it, too."
Lambert applauds recent state efforts to help nurses already living in rural areas to get advanced degrees. Knowing about the community and its people is an important advantage.
"They kind of have a feel for what the community has to ask for already," said Lambert, a former Franciscan nun who had worked and studied in other states before returning to Onamia, where she graduated high school. Her parents still live nearby.
One common pitfall for rural nurse practitioners is isolation. Lambert encourages small town practitioners to meet and support one another. She is a member of the North Central (Minnesota) Nurse Practitioners, a group of more than 20 that has been meeting since the late 1970s. Members share frustrations and insights about dealing with clientele, colleagues and administration. "Being involved in organizations helps one be prepared a little bit more for the future," she says.
Despite the isolation, however, Lambert feels rewarded in her job. One big reason: in her setting, the work encompasses the entire patient spectrum from prenatal to geriatric care.
She also feels gratified at the results.
"I find my job very satisfying most days because I can see a difference on a one-on-one basis," she says. "There are always the challenges that go along with systems — having to fit into them and jump through hoops just to get along — but I've been here plenty long enough to recognize when people appreciate what's being done. And that helps."
The job independence is another plus — "not having to ask somebody to sign a piece of paper saying, 'Yes, you can order this lab test or you can prescribe these medications.' " She also feels she is surrounded by plenty of capable professionals to whom she can refer patients.
"It does feel good to be able to do a complete thing for a patient," she says.
And others notice. Kosiba was impressed, for example, by Lambert's quick response to a patient who came to Ne-ia-shing Clinic with a blood clot. Lambert called the Onamia emergency department, "She said, 'This person needs to be seen right away.'She had everyone's backing," said Kosiba.
Finding a Balance
Having a balance in life is advice Lambert shares with not only prospective nurse practitioners but all nurses. She has seen the effects of job burn-out — working too many hours and sometimes discouraging caseloads — in the constantly changing health care staff in her area. Although she strongly encourages community involvement, she cautions that nurses "have a life other than their job."
Lambert fills her spare time with her 11 Arabian horses. She often takes several of the horses on the road to participate in distance and endurance competitions — 50-mile runs. Lambert hired a fellow nurse, Cindy Bauer, an LPN who works at Lake Mille Lacs Health System, to help keep the horses in shape on her five-acre farm outside of Onamia.
The horses' routine care requires Lambert to keep a schedule. That means she strictly follows a 40-hour work week with no burnout-inducing overtime.
Says Lambert: "I have to go back and take care of them."