Numerous cultural and historical factors need to be understood and respected when providing nursing care for Native American elders. For many Native Americans, it is an intrinsic value that elders are wisdom keepers. Elders have successfully navigated the path through unprecedented challenges, including genocide (Brown, 1970; Struthers & Lowe, 2003) and ethnocide (Charney, 1994; Clastres, 1988) of their nations and cultures. The list of American genocidal policies includes mass execution (Andregg, 2008), biological warfare (Fenn, 2000), forced removal from homelands (Young, 1958), destruction of the family structure through forced boarding school attendance (Adams 1995), relocation programs aimed at assimilation, incarceration without due cause, indoctrination of non-indigenous values, forced surgical sterilization of Native American women (Torpy, 2000), and prevention of religious practices (Locust, 1988).
Many of these and similar policies were in place until the American Indian Religious Freedom Act became law on August 11, 1978. Forty years after the United Nations approved the Convention on the Prevention and Punishment of the Crime of Genocide, President Ronald Reagan signed the Genocide Convention Implementation Act of 1987 on November 4, 1988, officially recognizing the crime of genocide and making the United States the 98th nation to ratify the agreement. However, the United States has never acknowledged accountability for treatment of its indigenous people.
The Importance of History and Worldview
When caring for Native American elders, it is imperative to understand not only the context of their lives, but their histories and worldviews as well. In their lifetimes, Native elders have either witnessed or heard the oral histories of genocidal assaults on their people and relentless attempts to destroy and exterminate their cultures. For example, the massacre at Wounded Knee, South Dakota, occurred 122 years ago; the Wounded Knee uprising only 39 years ago; and the largest mass hanging in U.S. history just 150 years ago in Mankato, Minnesota, with 38 Native American men losing their lives (Andregg, 2008).
Additionally, citizenship was not granted to Native Americans until the Indian Citizenship Act of 1924 (Kappler, 1929), although they fought alongside U.S. forces in every conflict or war in which this country was involved. As indigenous elder Agnes Baker Pilgrim (Taowhywee) so eloquently stated, “This is what started the trail of tears for my people and here in North America. Because of that (Referring to the edict issued by the Sixth [Catholic] Pope in 1943), I think that has strengthened our people to want to fight, to struggle, and to keep on. It’s a legacy, I believe, a legacy of survival” (Grandbois & Sanders, 2009, p. 573).
The pain of these unacknowledged, unmitigated atrocities continues in oral histories that are passed down from generation to generation. For elders in their 80s and 90s, many of these stories are firsthand accounts of their parents or grandparents.
Given this history, it is not surprising that many Native Americans have a genuine, deep-seated fear of institutions and government agencies, including health care and long-term care (LTC) facilities. This fear is founded on reality-based trust issues that have been inculcated into the very essence of their lives. An aging Native man shared with the first author that he is unable to swallow prescribed medications because of childhood memories in boarding school where he was given unidentified “pills” that he suspected were experimental in nature without his or his parents’ consent.
Nurses who care for elder Native Americans need to be sensitive to elders’ apprehension when receiving health care. It is helpful to provide reassurance and display patience with the lengthy process it takes for nurses to earn elders’ trust. Nurses are wise to volunteer in Native communities, engaging in activities such as serving meals to elders at a powwow or council meeting, hosting a booth at a tribal health fair, or speaking on a health topic of interest to elders as they enjoy their lunch at a tribal elder center. Such service with compassionate intent shows respect and willingness to accommodate the needs of elders. It also affords nurses the opportunity to learn about local Native cultures.
The first author, who is a member of the Turtle Mountain Band of Chippewa Indians, has 5 of 10 family members who are boarding school survivors; the parents of the second author, who is Oglala Lakota, are as well. The third author is married to a Comanche tribal member whose grandfather, Eschiti, was a leader of the last Comanche band forced by near-starvation to give up a nomadic way of life on the Southern Plains and surrender as prisoners at Fort Sill in Indian Territory (now the state of Oklahoma), to be placed on reservation land (Gwynne, 2010). They had to give up the life they knew that revolved around the buffalo. Wallace and Hoebel (1952) related:
The whites promised to furnish the Comanches with supplies until they should become self-sustaining, as well as with cattle to enable them to start herds.... In short, nothing was asked of the Comanches except that they should no longer be Comanches.
These personal, historical accounts are provided as a means for nurses to understand the context in which many Native elders live today, which can adversely impact health status.
Boarding school experiences and institutionalization can foster belief that when a vulnerable individual, such as a child or elder, was “taken or sent away” they never returned (Adams, 1995). Thus, one can imagine the terror felt by an elder placed in a LTC institution many miles from their reservation home. Because LTC facilities are rarely available in Native American communities, there is little firsthand experience to help alleviate these fears.
Unfortunately, there is a growing need for LTC services in Native populations due to significant health disparities (Jones, 2006) and high rates of disability. Native Americans experience higher incidence and prevalence of many chronic diseases, including diabetes and its complications, cancer, and cardiovascular disease (Indian Health Service, 2008). Among adults 65 and older, 57.6% of Native Americans are disabled, compared with 40.6% of White Americans (U.S. Census Bureau, 2003).
The Role of the Family
For some Native elders, families often serve as caregivers. The caregiving experience has been found to be positive, despite extra burden. In an investigation of caregiving by Native family members for reservation-based Native elders, Jervis, Boland, and Fickenscher (2010) noted:
The fact that assisting an elder was viewed in such positive terms among participants who live in a rural community struggling with poverty, trauma, high levels of alcohol disorders, and cultural traumatization may seem surprising.... Perhaps adverse circumstances such as these—and elders’ roles in providing respite from such difficulties—combine with cultural expectations for caregiving, traditional positive attitudes towards elders, and the normative interdependence of the Native family to produce a desire to reciprocate to elders who are perceived as giving so much to their families both in the past and present.
Thus, nurses employed in nursing homes, hospitals, clinics, and home care who are serving Native elders need to be cognizant of meeting families’ requests for information and support. Many elders need family to be present during contact with health care providers for emotional support, as well as to ask providers questions and synthesize information. Some Native elders are timid in the presence of physicians. They may also have difficulty understanding medical terms that those of younger generations can convey to them in words that have meaning to elders.
Perspectives on Illness and Wellness
As health care professionals who serve Native Americans, we have seen firsthand the devastating consequences of health disparities among them. The scientific and academic communities have come to acknowledge that Native people often have a concept of life and health that is far broader than the absence of disease, but rather includes the full spectrum of life, including the spiritual, emotional, mental, and physical dimensions. From their holistic perspective, life must be lived in a synergistic balance to support a strong, healthy person and family (Warne, 2008). When imbalanced, illness can result, and treatments must be directed at restoring this holistic balance. As such, Native elders may incorporate traditional healing practices into treatment or wellness practices (Struthers, Eschiti, & Patchell, 2004). Nurses need to be supportive of these choices and provide privacy for ceremonial healing activities.
In summary, nurses need to practice cultural sensitivity when interacting with Native elders. Nurses can learn about cultural practices of tribal people in their geographic areas by spending time in service in local Native communities. These actions will build a bridge of trust, which facilitates quality nursing care.
Finally, Native people have a longstanding tradition of respect for elders. The Ojibwa Tribal Code has the following as one of its tenets: “Honor the aged; In honoring them you honor life and wisdom” (Carson & Hand, 1999, p. 167). We close this editorial asking that the wisdom reflected in this tenet be your motto when caring for Native elders.
Donna M. Grandbois, PhD, RN
Assistant Professor of Nursing
College of Pharmacy, Nursing, & Allied
North Dakota State University
Fargo, North Dakota
Donald Warne, MD, MPH
Master of Public Health Program
North Dakota State University
Fargo, North Dakota
Valerie Eschiti, PhD, RN, AHN-BC,
College of Nursing
University of Oklahoma Health Sciences
Oklahoma City, Oklahoma
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