Earth, Wind, Fire and Water

The logo for the Kahuawake Schools Diabetes Prevention Project in Quebec uses a medicine wheel diagram to illustrate the concept that “healthy eating habits and daily physical activity can prevent diabetes.”

“Americans Indians and Alaska Natives feel very strongly about traditional beliefs because they define who we are. Many of us were born and raised in environments where these teachings are passed down. It is not a matter of simply keeping these values and practices alive; it’s a cultural necessity.”

Is this a traditional medicine man speaking? No, it’s a modern-day nurse—Lillian Tom-Orme, PhD, MPH, RN, FAAN, research assistant professor at the Health Research Center, Department of Family and Preventive Medicine, at the University of Utah in Salt Lake City. A member of the Navajo (Diné) Nation, she is also president-elect of the National Alaska Native American Indian Nurses Association (NANAINA).

Who better to understand the significance of traditional American Indian or Alaska Native health care treatments than a nurse who shares the same beliefs, or at least understands them? In areas with large indigenous populations, such as reservations, there is great demand for culturally sensitive nurses who respect and honor native beliefs. In fact, the Indian Health Service, the principal federal health care provider for Indian people, gives preferential treatment to hiring health professionals who are of American Indian or Alaska Native descent. In addition, some tribes own and operate their own health care facilities.

Following American Indian and Alaska Native health care rituals not only keeps the traditions alive, but also provides comfort to patients who believe in and practice them. Even when native patients trust modern health care techniques, traditional treatment methods may offer an additional sense of security.

Common Beliefs

Although traditions vary from tribe to tribe, and even among members of the same tribe who live in different regions, there are basic Indian beliefs about health that extend beyond tribal boundaries. Perhaps the most common is the importance of prayer for maintaining health and treating illness.

“Prayers are emphasized as a part of daily life,” comments immediate NANAINA Past President Bette Keltner, PhD, RN, FAAN, dean of the Georgetown University School of Nursing in Washington, D.C., and a member of the Cherokee tribe. “In some tribes, it is inappropriate to pray for oneself—the beneficiary of prayers will be another person. This practice emphasizes how important family and community is in American Indian culture, because you cannot pray in isolation.”

Similarly, American Indian and Alaska Native cultures revere elders. People of advanced age are viewed as special because of their life experiences and wisdom. They often serve as counselors to communities and are the proponents of tradition because of their direct ties with the past. American Indians and Alaska Natives also consider their entire tribe as an extended family.

One of the most important members of a tribe is the medicine man or woman. Although patients of Indian descent may visit a modern health care clinic regularly and even spend time in the hospital when necessary, many also want to be seen and treated by a traditional healer.

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However, many patients do not realize they have the right to use traditional medicine in a hospital setting—a cultural communication gap that American Indian and Alaska Native nurses can help fill.

“Some older patients don’t ask to see medicine men, so nurses should offer to contact one for them,” suggests Dottie Whipple, LPN, a member of the Dakota/Lower Sioux tribe who works for the IHS in Martin, S.D. “When I worked in [a health care facility in] northern Minnesota, we were able to bring in a medicine man or someone to pray with the patients.”

Natural remedies, such as herbs and roots, also play an important part in the healing process. Many American Indians or Alaska Natives drink teas brewed from herbs to maintain good health or to treat ailments. Spending time in sweat lodges is another popular practice, especially for treating drug or alcohol abuse; the heated environment and the sweating are believed to purify the body. Ironically, tobacco is often used in healing ceremonies because it is viewed as a gift from the earth that can cleanse the environment and is a medium of communication with the Great Spirit.

Minority nurses who share this cultural heritage not only have the advantage of being aware that Indian patients may be using these treatments, they also may be able to help patients use these remedies in combination with modern health treatments.

Another widespread Indian health belief that is finding its way into modern health care practice is the medicine wheel or circle of life—a diagram of a hoop or circle divided into four sections, representing mental, physical, emotional and spiritual principles. The number four itself is considered sacred in Indian culture, as there are four primary laws of creation—Life, Unity, Equality and Eternity—as well as four directions and four seasons. Other medicine wheels are based on the four traditional forces of nature: Earth (sustenance), Wind (momentum), Fire (energy) and Water (cleansing).

Because the medicine wheel combines several aspects of life, doctors and nurses who work in American Indian or Alaska Native communities are increasingly using medicine wheels to develop culturally competent health care education and treatment programs. For example, Vera Franklin, CADC, executive director of the Ahalaya Native Care Center in Oklahoma, uses a “recovery medicine wheel” to counsel chemically addicted patients living with AIDS. The Kahnawake Schools Diabetes Prevention Project, which serves a Mohawk community near Montreal, Canada, is one of several successful programs that use the circle of life to teach healthy lifestyle habits.

There are a number of common beliefs surrounding death as well. Indian nurses who understand these beliefs can comfort and communicate with their patients more effectively than nurses without this cultural awareness. According to Erna Johnson, RN, director of nursing at Parker Indian Hospital in Parker, Ariz., and a member of the Quechan tribe, one Navajo belief is that when people die at home, their spirits remain in the home; therefore, many patients choose to die in the hospital. Tom-Orme adds that Diné women who view the hospital as a place to die may choose not to give birth there.

Johnson notes that one Pima belief that is shared by several other tribes is that any body part that is removed during life, such as by amputation, must be put back with the body when a person dies. Otherwise, the person will go on to the afterlife incomplete. In Papago (Tohono O’odham) culture, when a person dies, the family bathes the body and combs his or her hair. All hair that comes out in the brush or on the floor must be bound and placed with the body so the spirits will take the deceased person with them.

Complementary Care

Today’s American Indian and Alaska Native nurses often combine traditional remedies with modern health care treatments, giving their native patients the best of both cultural worlds.

“I combine traditional and modern treatments for my own care and for others, too,” Whipple says. “When my husband gets a cold, he takes cold medicine; I eat my [medicinal] berries. Our reservation was very small, but I grew up with all the ceremonies, and my dad used herbs. I didn’t go to the doctor very often.”

However, just being of American Indian or Alaska Native descent doesn’t necessarily qualify a nurse to make decisions about using traditional remedies or to know how to combine them with modern treatments, Keltner cautions. Making the correct choice requires nurses to consider several factors, including their own capabilities.

“Nurses must assess the patient’s needs and recognize that some conditions require certain treatments; for example, appendicitis might require surgery. On the other hand, some conditions could be complemented with traditional healing methods to foster recovery,” Keltner explains. “In those cases, an Indian nurse must evaluate whether to refer the patient to a traditional healer or whether she is capable of providing the healing herself.”

The former NANAINA president goes on to emphasize that health is a cycle—a person may experience illness and then have a period of good health. She says that American Indian and Alaska Native nurses are “keenly aware of the spiritual aspects of health and illness” and understand that spirituality can “facilitate good health.”

When traditional healers are allowed to work in a hospital setting, they must be given the space and tools they need to do their jobs. Johnson, who spent a long time working with the Tohono O’odham tribe in Arizona, recalls that at the hospital where she worked, there was a room set aside for healing rituals. The hospital staff removed all the oxygen tanks from the room so that the medicine man could light candles for his rituals.

“It makes sense that we incorporate these [traditional] values into our practice,” Tom-Orme says. “A friend of mine put this very nicely when he said that, ‘as native professionals, we have to understand that traditional medicine works from within to the outside.’ Modern medicine, in contrast, works from the outside inward as we ingest medication into our bodies.”

Getting the Point Across

Because linguistic competence is an important aspect of providing culturally competent care to ethnic minority patients, American Indian and Alaska Native nurses who speak the native languages of their patients are in high demand. Most health care facilities located on or near reservations, or in areas with large Indian populations, employ a number of nurses and other personnel who can translate for patients.

“When an American Indian is very ill, that person may revert back to his or her native language, even if that language is not used very often,” Whipple explains.

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On a deeper level, getting patients to understand the medical consequences of their actions poses a challenge for nurses. Lifestyles and traditions that have been handed down from generation to generation—such as the traditional use of tobacco—factor into a number of prevalent health problems among American Indians. At the same time, many illnesses that are serious concerns in Indian communities, such as diabetes, high blood pressure and cancer, are relatively new to this population, because they were brought to this country by immigrants from Europe. In fact, Indian languages don’t even have a word for “diabetes” or “cancer.”

“This is why we are struggling with the problem of diabetes in our communities,” Tom-Orme comments. “Nurses must take into consideration the broader framework to explain diabetes and other chronic and persistent health problems. Indian people are now beginning to discuss these issues in public forums. The Navajo Nation is trying to standardize the diabetes ‘language’ so that we are all speaking about the diabetes pathology and health concepts the same way, to avoid misunderstanding and to improve outcomes.”

One way that American Indian and Alaska Native nurses are able to educate their patients to prevent and treat illness is by showing genuine interest in the community’s health. On many reservations, community educators and outreach programs have proven to be effective in getting patients and their families to comply with prescribed care. The Indian Health Service and other health organizations have established successful programs in which nurses or other caregivers visit patients’ homes.

“I see a lot of denial, especially in people with diabetes,” Whipple says. “At the IHS, we have outreach programs that continue to follow up with patients. We send letters or make home visits. A lot of patients finally become convinced that [health care] is important because someone cares enough about them to keep coming back.”

Blending old traditions and new techniques into an effective health care practice is a challenge even for nurses who are intimately familiar with American Indian beliefs. For nurses who have not grown up in this cultural environment, college and nursing school programs can help familiarize them with native beliefs—but Keltner warns that such information does not prepare nurses to provide traditional Indian remedies.

“One of the risks is that in an already-crowded nursing curriculum, students will only get an overview or survey,” she explains. “That does not give you the knowledge to go out and practice those methods. Nevertheless, nursing should be an interactive and personal profession. There’s no way to ignore the responsibility of learning about other cultures.”

With so much of their culture having been destroyed, lost or assimilated into other cultures, it’s no wonder that American Indians and Alaska Natives want to hold on to their traditional health care practices and beliefs. Nurses who can integrate these beliefs effectively into their modern practice are not only helping their patients to stay healthy but are also helping to preserve an important part of the past.