As I looked out of the cockpit window of a single-engine Cessna, I saw patches of fog drifting over the mountains of the Superstition Wilderness, scars of a copper mining dig and, now and then, a small town in the rugged hills below. The plane dipped slightly and with two revs of its engine announcing my arrival, circled to land in one of the many isolated, rural American Indian communities of Arizona. My task in this Indian community was to assess the continuing education (CE) needs of the nurses practicing there. Some impressions and considerations for entering an Indian community for this purpose will be discussed.
Arizona has the second largest American Indian population in the US.1 Many of the Indians live on reservations, often in small, rural communities scattered throughout the state.
Health care for the Native American is provided for through the US Public Health Service hospital system. Many of these hospitals are located in isolated communities where the Indians live. Nurses working in these settings also are isolated and have little opportunity to participate in educational programs which support their nursing practice. Upgrading their nursing practice by keeping abreast of newer developments in health care through continuing nursing education is often difficult because of the location of most programs. Little has been done to bring continuing nursing education programs to nurses who care for Indian clients in rural communities.
As an Anglo nurse and a novice at assessing the educational needs of nurses caring for Indian clients, I entered the Indian community with some apprehension. A review of nursing literature was helpful in understanding cultural health traditions from the American Indian perspective.2 Especially helpful were comparisons made between Indian and Anglo health practices. Primeaux noted that in the Indian culture there is little distinction between mediane and religion and that this relationship is likely to be overlooked by the non-Indian health worker.3 Kneip-Hardy and Burkhardt suggested that the Anglo nurse caring for Indian clients needs to be aware of the Indian's differing customs and lifestyle and be willing to make adaptations to accomodate their cultural needs.4 Specific considerations for entering the Indian community to assess the continuing education needs of nurses caring for the Indian client, however, has not been addressed in the nursing literature.
Since this was a project supported in part by a National Institute for Mental Health grant and I was the Mental Health Project Coordinator, the assessment focused on the educational needs of nurses in the area of mental health. My purpose was to assess the nurses' needs for CE programs regarding mental health aspects of patients' care and to identify the specific areas of concern.
Initial Observations and Contacts
Two cultural orientations must be considered when entering the Indian community. Anglo as well as Indian nurses care for patients in US Public Health Service hospitals. The Anglo nurse, however, is usually a registered nurse, while the practicing nurse or nursing assistant is more likely to be an American Indian. Often, the director of nursing is not a member of the Indian majority. Thus, when entering the community, rapport must be established with Anglo as well as Indian nursing personnel in the hospital. Since the relationships within the institution are unknown or at best only guessed at, a lowkeyed, tactful approach is required. Sensitivity to the protocol of the hospital and community is essential.
My contact with a person in the Indian community began with a telephone call to the director of nursing in the US Public Health Service hospital. The purpose of the call was to set up an appointment for a meeting to determine the need for and interest in CE nursing programs. A call was more efficient than a letter because questions could be answered and an appointment time could be verified immediately. The telephone call was followed by a letter to confirm the date and time of the appointment and/or to clarify other arrangements.
At the time of the appointment, the director of nursing was given copies of a mental health needs assessment tool for distribution to the nursing staff. On the form, the nurses were asked to identify the mental health problems most often encountered in their nursing practice. The assessment tool facilitated prioritizing the nurses' specific educational needs. Programs based on the identified mental health needs of patients then could be planned.
Since topics related to mental health aspects of patient care may also have relevance for non-nurses, I visited other mental health care agencies in the community. Even in this small Indian community I found a mental health clinic, a child treatment center, and a tribal alcoholism program. The educational needs identified by the personnel in these agencies paralleled the mental health topics identified by the nurses. Consequently, mental health issues were of concern to a wide range of health care providers in the community and not exclusive to nurses.
As an Anglo nurse and educator entering the Indian community for the first time, I had certain preconceptions about the Indian culture. One stereotype, derived from the literature, was that Indians tended to be non-verbal and passive. I anticipated that this might also apply to Indian nurses. This stereotype did not apply, however. After an initial awkwardness, which could be expected in any new situation, the nurses were warm, responsive and shared experiences freely.
Another expectation was that the Indian nurses themselves would be knowledgeable about their culture and heritage. Indeed, I looked forward to learning about the Indian culture from their perspective. I was surprised when a group of Indian nurses in an urban center identified a course about Indian culture as a CE need. Although Indian, the urban nurses had a desire to understand better the background of the patients coming to the hospital from various rural Indian communities. Thenlearning needs in this respect were similar to those of non-Indian nurses caring for Indian patients. I was inaccurate in generalizing about Indian nurses, and recognized that they were as individually different as persons within any ethnic group.
Attitudes and Commmunicatlon
The attitude of the person entering the Indian community to assess, plan or present a CE nursing program is important. Joe, Gallinto and Pino stated that many Anglo health professionals bring a condescending and "superior" attitude to the Indian community, preventing the Indians from receiving the services health professionals have to offer.2 I found that it was more effective to try to learn from the people in the community if I did not pose as "the expert" or authority. The nurses and other health care workers know the individuals and families in their community very well. Listening as they shared their experiences was helpful in assessing needs and determining the most effective teaching approach. This also made it possible to relate mental health concepts to their specific situations.
I was careful not to project my own cultural values when relating with Indian nurses and other health care persons. Coming from a culture where the Protestant work ethic is valued, I did not assume that this was a value for the Indian client. Primeaux stated that "the biggest mistake that health care providers make in working with culturally different persons is the transference from their own cultural background of their expectations of how certain people behave or should behave in a certain situation."6 Entering with the attitude of "desiring to learn" as well as assess or teach helped to minimize this tendency.
A major area of conflict in any transcultural situation results from misunderstandings in communication. When I was unsure of the differences in cultural practices, I did not assume but tried to clarify communication by asking questions. For example, the topic of disciplining children came up on one occasion and I asked, "Do Indian mommies spank their babies?" By paraphrasing and asking for validation, I determined whether or not my understanding was accurate. The Native American nurses patiently anewered my questions and when a situation was unfamiliar to me, they explained it. In this way, I attempted to communicate an attitude of trying to understand their CE nursing needs from their unique perspective.
Although it is important to learn as much as possible about the culture that we enter, we need to remember that people of a different cultural background are basically more similar to us than we often believe them to be. Carl A. Hammerschlag, a Chief Psychiatrist for the Indian Health Service, suggested that perhaps we focus too much on the differences between the Indian and Anglo cultures rather than on the human characteristics we have in common (personal communication, Dec 29, 1980). The need for respect, dignity and a sense of worth is common to all of us regardless of our cultural orientation.
Findings end Recommendations
Nurses caring for Indian clients in this community identified alcoholism and the concomitant problem of depression with the potential for suicidal behavior as a priority CE need. Consequently, a workshop on alcoholism was recommended. Because of the distance to the Indian community from the institution offering the program, an intensive one- or two-day workshop seemed feasible. The CE providers and program presenters would be required to make only one trip. Also, a great deal of information on alcoholism could be presented in a concentrated period of time.
A practical consideration when planning a CE offering is the location for the program. Such mundane concerns as housing and food must be planned. My assessment of the community also included these aspects of program planning. I found that the community did not have a motel or hotel and that the only restaurant in town had closed the week before my arrival. Obviously, I needed to look at other alternatives.
I learned that high school students from the Indian community attended a school in a neighboring rural town. The town had adequate facilities to accommodate a workshop. Including another community also would broaden the impact of the workshop by making it available to more nurses and health care providers.
Timing of the workshop was important to the success of the program offering. The special circumstances in the hospital and community during the time of the proposed workshop needed to be considered. It was necessary to work closely with the director of nursing of the local hospital to coordinate schedules. The workshop needed to be scheduled at a time when other events did not take priority. For example, it would not be appropriate timing to conduct a workshop the week that the hospital was to be reviewed by an accreditation team.
Also, enough lead time must be allowed in order to plan the workshop. The director of nursing at the US Public Health Service hospital suggested that she be informed at least six weeks in advance of the date of the program in order to make arrangements for staff relief from clinical assignments.
Entering an Tndfon community to assess nurses' continuing education needs required that I be sensitive to the protocol of the hospital and other agencies in the community. I entered with an attitude of learning as well as assessing the educational needs of nurses working with Indian clients. Avoiding stereotyping and clarifying communication made it possible to accurately assess the special mental health problems of Indian clients as perceived by their health care personnel. These problems were then prioritized and the CE needs of the nurses in the community were assessed.
Alcoholism and the related problems were identified as priority CE needs in the Indian community. Further assessment of the community, and time and distance considerations suggested that an intensive one- or two-day workshop on these topics would be most efficient and economical. Because the Indian community lacked the appropriate facilities for conducting a workshop, I recommended that the workshop be held in a neighboring rural town. This also extended the program offering to nurses and other health care personnel from a wider geographical area.
The cooperation, time and interest of the director of nursing and other significant persons in the community were essential to assessing nurses' continuing education needs for this Indian community.
- 1. Taylor TW: The States and Their Indian Citizens. Washington, DC, US Department of Interior, Bureau of Indian Affairs, 1972.
- 2. Joe J, Gallerito C, Pino J: Cultural health traditions: American Indian perspectives, in Branch MF, Paxton PP (eds): Providing Safe Nursing Care for Ethnic People of Color. New York, Appleton Century Crofts, 1976, pp 81-98.
- 3. Primeaux MH: Caring for the American Indian client. Am J Nurs 1977; 77:91-94.
- 4. Kneip-Hardy M, Burkhardt MA: Nursing the Navajo. Am J Nurs 1977; 77:95-96.
- 5. Primeaux MH: American Indian health care practices: a cross-cultural perspective. Nurs Clin North Am 1977; 12:55-65.