Nursing Educational Diversity for Native American Cultural Ethnicity
What Is American Indian/Alaska Native Culture
The US Census Bureau (2010a) has identified more than 5.2 million
people (almost 1.7% of the US population) who are members of the American
Indian/Alaska Native ethnic group (Norris, Vines, & Hoeffel, 2011). More
than 500 distinct tribes of American Indians and Alaska Natives exist,
including Eskimo and Aleut tribes (Lowe & Struthers, 2001). The largest of
these tribes is the Cherokee.
Other tribes of significant size are the Navaho,
Sioux, Chippewa, Choctaw, Pueblo, and the Latin American Indian. These tribes
reside primarily in the northwestern, central, and southwestern regions of the
United States (Norris et al., 2011). The term Native American is used
throughout this section of the chapter to include both the American Indian and
Native Alaska people.
Approximately half of the members of this ethnic group are eligible
for health services provided by the federal government. The Indian Health
Service of the US Public Health Service maintains responsibility for providing health
care to them (Sequist, Cullen, & Acton, 2011; Sofer, 2017; USDHHS, 2015a).
Nursing Educational Challenges Related to Western ad Traditional Medicine
The current challenge to nurses is to integrate Western medicine
with traditional non-Western tribal folk medicine to provide cross-cultural
health education to Native Americans in reservation based communities across
the nation. To do so, nurses must understand contemporary cultural patterns
that set this ethnic group apart from non Native Americans, including their
theories of what causes various diseases and the associated treatments
(Cantore, 2001; Lowe & Struthers, 2001).
It is also essential for nurses to
become focused on a more ethno-medical orientation. This means understanding the
nature and consequences of illness problems and therapeutic interventions from
the ethnic group’s perspective, rather than adhering to the biomedical orientation
of defining diseases and treatment options from only a Western perspective.
The Native American concept of health and illness incorporates the
relationship of humans with their universe. Differences in beliefs, however,
may be found among the various Native American tribes in the United States.
Characteristics of Major Ethnic Group of Native American
The
following are major characteristics associated with this ethnic group as
addressed by Purnell (2013). Lowe and Struthers (2001). Harding (1998),
Scharnberg (2007), Joho and Ormsby (2000). Portman and Garrett (2006). and
Cantore (2001).
1. A spiritual attachment to the land and harmony with nature
2. An intimacy of religion and medicine
3. Emphasis on strong ties to an extended family network, including
immediate family, other relatives, and the entire tribe
4.The view that children are an asset, not a liability
5. A belief that supernatural powers exist in both animate and
inanimate objects
6. A desire to remain distinct and avoid acculturation, thereby
retaining one’s own culture and language
7. A lack of materialism, lack of time consciousness, and a desire
to share with others
These common characteristics can easily be overlooked by the nurse
when care is being provided to patients of this ethnic group. To some extent,
Anglo-American culture and Western healthcare practices have been integrated
into the Native American way of life. However, these seven characteristics
still predominate today to set this subculture apart as a unique entity.
Native Americans see a close connection between tween religion and
health. When a family member becomes ill, witchcraft is still perceived by some
tribes as the real cause of illness. In traditional societies, witchcraft
functions to supply answers to perplexing or disturbing questions. It also
explains personal insecurities, intra-group tensions, fears, and anxieties.
Some Native American tribes still practice witchcraft but tend to
deny it as a reality because of the negative stereotype and stigma attached to
it by outsiders. Nevertheless, the intimacy between religion and medicine
persists and is exhibited in the form of “sing” prayers and ceremonial cure
practices. However, few nurses would think of providing space and privacy for
several relatives to be able to conduct a ceremony for a hospitalized family
member.
Also, some Native American tribal beliefs require incorporating the
medicine man (shaman) into the system of care given to patients. The central
and formal aspects of Native American medicine are ceremonial, embracing the
notion of a supernatural power. Although the ceremonies vary from tribe to
tribe, the ideas of causation and cure are common to all Native Americans.
The
rituals performed are based on the signs and symptoms of an illness. In some
instances, family members also conduct these rituals. Cornmeal, from the sacred
food of corn, is an item that is frequently used in a variety of curative
ceremonies. Herbal remedies have for generations served native healers as their
pharmacopoeia. The nurse must demonstrate legitimate respect for such
ritualistic symbols and ceremonial activities.
To be without a family of many relatives is to be considered very
poor in the Native American world. The family and tribe are of utmost
importance, which is a belief that children learn from infancy. It is not
unusual for many family members sometimes large groups of 10 to 15 people-to
arrive at the hospital and camp out on the hospital grounds to be with their
sick relative. Talking is unnecessary, but simply being there is highly
important for everyone concerned.
Grandmothers are of particularly great importance to a sick child,
and they frequently must give permission for a child to be hospitalized and treated.
The Native American kinship system allows for a child to have several sets of
grandparents, aunts, uncles, cousins, brothers, and sisters. Sometimes numbers
of women substitute as a mother figure for a child, which may cause role
confusion for the healthcare provider.
Children are given a great deal of freedom and independence to
learn from their decisions and live with the consequences of their actions.
They tend not to be viewed as very competitive or assertive because to call
attention to oneself is interpreted by Native Americans as showy and
inappropriate.
They may appear spoiled, but in fact they are taught self-care
and respect for others at a very early age. Children are endowed on by family
members, and, in turn, they have high regard for their elders. In fact, the
older adults in Native American communities are highly respected and looked to
for advice and counsel.
Another characteristic of Native Americans is that they generally
are not very future oriented; they take one day at a time and do not feel they
have control over their own destiny. Time is considered to exist on a continuum
with no beginning and no end. Native Americans tend not to live by clocks and
schedules. In fact, many of their homes do not have clocks, and family members eat
meals and do other activities when they please.
Members of this ethnic group tend to be casual in their approach to
life. This lack of time consciousness and pressure is a crucial factor when a
prescribed regimen calls for the patient to follow a medication, exercise, or
dietary schedule. Inattention to time, in addition, can interfere with Native
Americans keeping scheduled appointments, although lack of funds rather than
time seems to be the main cause of missed appointments.
Another aspect of time is reflected in Native Americans’ belief
that death is a part of the life cycle. Their grievance processes are
culturally very different. Funerals are accompanied by large feasts and the
sharing of gifts with relatives of the deceased. The outward signs of grieving
may differ from tribe to tribe; some tribes believe that death and passage to
the afterlife should be celebrated, whereas others believe that tears ease the
passage to the afterlife, so mourning is expected.
Life after death is viewed
as an opportunity to join the world of long-ago ancestors. Native Americans’
view of death is closely related to their opinion about the appropriate
disposal of amputated limbs. Because diabetes is so prevalent in the Native
American population (O’Connell, Yi, Wilson, Manson, & Acton, 2010), it is
important to know that they usually want to reclaim an amputated body part for
proper burial.
Sharing is another core value of Native Americans. The concept of
“being” is fundamental, and there is little stress on achievement or material
wealth. Individuals are valued much more highly than material goods. Overall,
Native Americans are a proud, sensitive, cooperative, passive people, devoted
to tribe and family. and willing to share possessions and self with others.
They are very vulnerable when it comes to their pride and dignity, and they can
be easily offended by insensitive caregivers.
In terms of human relationships, Native Americans believe that to
look someone in the eye is considered disrespectful. Some tribes feel that looking
at the eyes of another person reveals and may even steal someone’s soul.
Even
though a friendly handshake and eye contact are acceptable and even expected in
the white American culture, it must be acknowledged that these gestures do not
have the same meaning for the Native American. Nurses may consider lack of eye
contact to mean that these patients are not interested in learning, or
inattentive, when in fact all along they were taking in the message of
instruction being given.
The type and incidence of health problems faced by Native Americans
have undergone significant change over the years. In the first half of the 20th
century, acute and infectious diseases were prevalent and were the main cause
of death. Today, because of increased life expectancy, Native Americans are
succumbing to many lifestyle diseases and chronic conditions (National
Institutes of Health, 2017).
Chief among the causes of morbidity and mortality
are heart disease, cancer, diabetes, and drug and alcohol abuse. The rates of
obesity, heart disease, suicide, and diabetes for the Native American
population are among the highest of all ethnic groups.
These issues and others
are amenable to educational intervention and need to be addressed by nurses
(Blue Bird Jernigan et al., 2017; Cwik et al., 2016; Gittelsohn & Rowan,
2011; Goodwin, Burhanstipanov, Dignan, Jones, & Kaur, 2017; Jemigan, Duran,
Ahn, & Winkleby, 2010; Komro et al., 2017, Muller et al., 2017, O’Connell
et al., 2010; Sequist et al., 2011; Sofer, 2017; Varcoe et al ., 2017: Veazie
et al., 2014).
Teaching Strategies for Native American Culture
The Indian Health Service is a government operated health system
established in 1955 to meet federal treaty obligations to provide hospitals and
outpatient clinics for the delivery of healthcare services to 2 million of the
country’s 5.2 million Native Americans belonging to 565 tribes.
With the
increased focus on using health information technology and tele-medicine to
deliver prevention and medical management programs, important achievements have
recently been made in improving diabetes control and increasing life
expectancy.
Nevertheless, health disparities persist in this ethnic population
as compared to the overall US population (Sequist et al., 2011; Sofer, 2017).
The Health Education program of the Indian Health Service is committed to actively
influencing wellness behaviors and good lifestyle choices through health
promotion and disease prevention efforts (USDHHS, 2015a).
Although all Native Americans share some of the core beliefs and
practices of their culture, each tribe is unique in its customs and language.
Finding the ways and means to integrate Western medicine with the traditional
Native American folk medicine in caring for the varied needs of this population
group presents a challenge to the nurse.
It also presents a learning
opportunity for the learner who is receiving these health education services.
Nurses need to focus on giving information about these diseases and risk
factors, emphasize the teaching of skills related to changes in diet and
exercise, and help clients to build positive coping mechanisms to deal with
emotional problems.
Preparing
Nurses Educator for Diversity Care in Native American Culture
The United States is no longer the homogeneous melting pot society
once it was. Today, numerous, varied, and distinct cultures are present in the
United States because of an increasing trend toward global migration of people
and a change in philosophy about respecting cultural diversity.
In addition,
nurses are caring for people from many cultures because of the globalization of
nursing practice and the professional emphasis on transcultural care and
cultural competence in practice (Betancourt, Corbett, & Bondaryk, 2014;
Burchum, 2011; Cai, 2016; Raman, 2015; Smith, 2013). Multiculturalism as a
relatively new concept promotes awareness and acceptance of diversity and attention
to the healthcare needs of unique populations (Truong, Paradies, & Priest,
2014; Vidaeff et al., 2015).
The delivery of appropriate health care now and in
future years depends on use of a culturally informed approach that goes beyond
simple language translation and an understanding of the characteristics of
different cultures. As primary caregivers, nurses must learn how to relate to
people including patients and their family members, fellow healthcare
practitioners, and nursing students who come from a variety of cultural
backgrounds (Jeffreys, 2016).
As part of former President Bill Clinton’s national leadership to
eliminate cultural disparities in health by the year 2010, the US government
introduced a series of initiatives put forth in the Healthy People 2010
document. One goal of this 10-year plan was to eliminate racial and ethnic
disparities in health (USDHHS, 2000). This initiative has been praised as being
“the first explicit commitment by the government to achieve equity in health
outcomes” (Jones, 2000, p. 1214).
The nursing profession embraced this goal to
eliminate discrepancies in health outcomes among minority populations (Carol,
2001). Since then, a follow-up Healthy People 2020 document has been released
(US-DHHS, 2012).
The profession continues to contribute to the expectation of
eliminating these disparities by focusing on change in both academic and
practice settings as well as through clinical research (Shen, 2015; Singer,
Dressler,George, & The NIH Expert Panel, 2015).
One important step to
ensure culturally competent nursing care in this new century is to increase
minority representation in nursing. The profession needs to recruit and retain
more minority students and faculty to expand the diversity of RNs within its
ranks (Carthron, 2007).
Unfortunately, people from minority groups comprise
only 16.8% of the nursing workforce, whereas more than 34% of the
total US population belongs to a variety of cultural subgroups (US Census
Bureau, 2011).
Another initiative to break down cultural barriers to health
care calls for strengthening multicultural perspectives in the curricula of
health education programs, including nursing education (Kratzke & Bertolo,
2013; Mikkonen, Elo, Kuivila, Tuomikoski, & Kaariainen, 2016; Perez &
Luquis, 2014).
Nurses must be able to create an environment in which people are
encouraged to express themselves and freely describe their needs. An emerging
paradigm, cultural distress, describes patient reactions to care when nurses do
not attend to a person’s cultural needs (Dewilde & Burton, 2016).
As Dreher
(1996) so aptly stated many years ago, “Transcending cultural differences is
more than an appreciation of cultural diversity. It is transcending one’s own
investment in the social and economic system as one knows it and lives it” (p.
4). Nurses must concentrate on the cultural strategies, such as cultural
humility (Isaacson, 2014), that are needed to help individuals and groups
negotiate the healthcare system.