Beyond Bonuses: Rethinking Retention in Indigenous Health Systems
“When you’re connected to people and to place, it reaches you spiritually.”
— Participant, It Reaches You Spiritually Study
This blog post is based on the paper It Reaches You Spiritually: A Qualitative Study of Relationships with People, Place, and Work Among Providers Working in Indigenous Communities in the U.S.
For decades, the Indian Health Service (IHS) and Tribally operated health systems have grappled with one of the most persistent challenges in rural healthcare: how to recruit and retain providers. Despite well-intentioned efforts—signing bonuses, loan repayment programs, relocation assistance—vacancy rates remain stubbornly high. The U.S. Government Accountability Office reported a 25% provider vacancy rate within IHS facilities as recently as 2018, with some specialties facing even greater shortages.
Financial incentives may bring people through the door—but they don’t necessarily keep them there.
A new qualitative study, It Reaches You Spiritually, offers a deeper look at what truly sustains healthcare providers serving Indigenous communities. Its findings remind us that effective retention is not just a matter of compensation—it’s about connection, belonging, and balance.
A Study Rooted in Relationship
Conducted by Cardea Services, Good Medicine Tribal Public Health Consulting, the Northwest Portland Area Indian Health Board, and The Raven Collective—with funding from the Minority HIV/AIDS Fund via the Indian Health Service—the study sought to understand what keeps healthcare providers working in IHS and Tribally operated settings across the U.S.
Seventeen providers—nurses, pharmacists, physicians, behavioral health clinicians, and others—shared their experiences. Most were women. Nearly one-third were American Indian or Alaska Native. They worked in small communities across six states, many rural or remote.
Unlike typical workforce studies, this one was grounded in Indigenous Ways of Knowing—approaching wellness as the balance between physical, emotional, mental, and spiritual wellbeing, and understanding human experience through relationships with others, the land, and purpose.
That relational lens shaped both the questions asked and the insights gathered.
What Truly Keeps Providers Rooted
The findings paint a picture of a workforce motivated not by bonuses, but by relationships, autonomy, and meaning.
Relationships as Retention
Providers described strong ties with patients, coworkers, and community members as what kept them in place.
“This is my community. I built connections and relationships here. I understand the need.”
For some, these relationships reached beyond friendship—they were a spiritual grounding that reaffirmed their calling to serve.
Autonomy and Support
Many participants highlighted the freedom to innovate and the trust placed in them by supervisors. Being able to design new programs—mobile units, outreach models, or expanded pharmacy services—was not just a professional perk but a source of fulfillment.
“It’s fulfilling to identify problems, create solutions, and actually implement them,” said one physician. “That flexibility makes all the difference.”
Meaning and Fulfillment
The study reframed “job satisfaction” as fulfillment—a sense of alignment between personal values and professional purpose. Providers spoke of their work as an extension of who they are.
“The work I do is connected to my core identity and values. I’ve made a commitment to this work, and it’s built on respect—I don’t take that lightly.”
Challenges that Undermine Balance
Understaffing, lack of work-life balance, and inadequate resources remain significant stressors. These factors limit time for rest, family, and self-care—core aspects of wellness in many Indigenous frameworks. Yet even in the face of these challenges, providers expressed deep commitment to the communities they serve.
An Indigenous Lens on Retention: Relationship as Policy
From an Indigenous perspective, wellbeing is inseparable from relationships—with family, community, ancestors, and the land. Retention, then, is not just about holding positions open—it’s about cultivating the conditions where providers can remain in right relationship with their work and with those they serve.
When policies ignore this relational reality, they risk treating people as replaceable resources rather than integral members of a healing ecosystem.
When policies honor it, the results are transformative. Connection becomes a form of care—for both providers and patients.
From Incentives to Belonging: Policy Implications
The It Reaches You Spiritually study offers clear guidance for policymakers, administrators, and funders who want to strengthen the I/T/U workforce:
Invest in belonging. Support initiatives that foster social and cultural connection—community welcome events, mentorship programs, and opportunities for providers (and their families) to engage meaningfully in local life.
Pair financial incentives with relational infrastructure. Bonuses alone can’t offset isolation or burnout. Policies should ensure access to housing, childcare, schooling, and social support—especially in rural areas.
Embed Indigenous frameworks of wellness into workforce design. Integrate Indigenous Ways of Knowing, reciprocity, and relational ethics into leadership training, HR policies, and organizational wellness strategies.
Protect provider wellbeing as a systems priority. Recognize that burnout reflects systemic imbalance. Build policies that honor rest, reflection, and balance—not just productivity.
Reclaiming the Heart of Retention
At its core, It Reaches You Spiritually challenges us to reimagine what it means to “retain” someone. True retention is not about locking people in—it’s about creating conditions that invite them to stay.
Providers stay when their work nourishes them, when they feel part of a community, and when their contributions are seen as meaningful. They stay when leadership understands that caring for caregivers is part of caring for patients.
In the words of one participant:
“When you’re connected to people and to place, it reaches you spiritually—you’re better at having a sense of purpose.”
That sense of purpose cannot be bought—it must be cultivated.
If we build systems that honor connection, balance, and belonging, we won’t just fill vacancies.
We’ll restore the spirit of Indigenous healthcare itself.
Citation:
Ambrose, G., Gardner, W., Cushman, N. et al. ‘When you’re connected to people and when you’re connected to the place, it reaches you spiritually’: a qualitative study of the experiences of providers working with Indigenous communities in the U.S.. BMC Health Serv Res (2026). https://doi.org/10.1186/s12913-026-15471-5