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Over 2.3 million Native American Indians live in the United States and the population is steadily growing (U. S. Bureau of the Census, 1991). At the turn of the last century, there were 220,00 Native Americans and Alaska Natives in the United States. Since 1980, the Native American census has increased dramatically as the populace was asked to self-identify according to ethnic background (U.S. Department of Commerce, 1983). This exceptional increase is partially due to improved health care for all ages and to an accelerated birth rate.
This may also represent a greater acceptance as being identified as Indian. Although there is no direct evidence of the reasons underlying this change, it is probably rooted in four additional factors: (1) the increased benefits from being included as an Indian in tribal roles, (2) the benefits of being identified as a member of an ethnic/racial population in seeking employment, (3) a somewhat lessened prejudice against Indians in society, and (4) a resurgence of Indian identity and pride.
Native American Indians account for only about 1% of the total U.S. population, yet this population has tremendous diversity as illustrated by 252 languages, 505 federally recognized tribes and 365 state recognized tribes.
The diversity is also seen in varying levels of cultural commitment among the members of a given tribe or nation based on variances in value orientation. Nevertheless, a prevailing send of "Indianness" based on a common world view seems to bind Native American Indians together as a people of many peoples.
During the time before contact with Europeans, it is estimated that there were about 2.5 million indigenous people representing over 300 distinct tribes in what would become the United States. Yet, by 1890, the year in which the Wounded Knee Massacre occurred, only 250,000 of this population remained. The 90% population reduction resulted from several major factors, all of which were partially supported by Federal policy concerning the "Indian problem"; disease, malnutrition, war and murder. Given the active attempts to exterminate this population or remove them from traditional lands, relocation policies, extreme poverty, deployment of their young people to boarding schools, and the introduction of alcohol and other drugs, the resiliency of many tribes is remarkable.
As a consequence of a pattern of internal colonialism whereby native populations are treated as if they were foreign colonies, life on the reservation remains grim, marked by high rates of poverty and its consequences: homicide, suicide, family violence, school failure, infant mortality, tuberculosis, alcohol-related diseases, and diabetes. Because relative poverty also characterizes Native Americans outside the reservations, their life expectancy is the lowest of all subpopulations in the United States.
The major factor in the improving economic status of Native American has been the introduction of gambling casinos on the reservations. Original treaties guaranteed tribal rights to local resources as well as freedom from control by state governments. For example, these conditions brought great wealth to the Oklahoma reservations, where oil deposits had been discovered earlier. More recently, the tribes have invoked the same treaty rights to exempt the reservations from state-level prohibitions against gambling establishments. As a result, casinos have opened on many Indian reservations, bringing jobs and millions of dollars in profits to formerly poverty stricken tribes.
There has also been a revival of Native American cultural pride and an increasing interest in preserving the diversity of tribal history, customs, and crafts. Perhaps all these trends together will finally bring hope and help to the tens of thousands of Native Americans still trapped in the cycle of poverty, disease, and violence.
Since it is evident that Native American society is pluralistic, "tribal identity" may be a more useful way to operationally define cultural identity. The first self-identifier for Native Americans is usually membership in or affiliation with a specific tribe or tribes. Each tribe has its own unique set of beliefs which are influenced by contact with both non-Indian culture and other Native American groups. Therefore, there are hundreds of belief systems held by Native American Indians and Alaska Natives. Most tribes seem to have the following beliefs in common. These beliefs should not be universally ascribed to every tribe and are meant to serve as a guide to further research and can provide healthcare professionals with a frame of reference when providing services to Native American clients.
There are many Native American value systems, just as there are in throughout the rest of society. With that caveat in mind, some commonly espoused values across tribes include the importance of sharing and generosity, allegiance to one's family and community, deep respect for elders, noninterference, courage, optimism, orientation to present time, emphasis on being over doing, preference for supernatural explanation of natural phenomena, harmony with nature, and contentment. This contentment comes from identification with the cosmos (feeling one with the world), a spiritual orientation to life, and traditional religious practices. Living in harmony with nature and with other human beings is of utmost importance, nature being a powerful learning tool for the individual, the family, and the tribe.
By contrast, mainstream values emphasize saving, domination, competition, materialism, doing, winning as much as possible, mastery over nature, a time orientation toward living for the future as well as "clock watching", reverence of youth, individualism, the nuclear family, and preference for scientific explanation of natural phenomena. Many of the problems facing Native Americans today result from a vast cultural conflict between Native Americans and mainstream culture. Many Native Americans experience conflict when they either try to internalize unfamiliar values of the dominant society or to practice the roles necessary for preservation of traditional values and practices.
Approximately 1.5 million Native American families in the United States are represented in 505 tribes. About half live on reservations. Because of the high degree of diversity among tribes, it is difficult to research Native American families. Nevertheless, some investigators assert that the family remains the basic unit of the Native American community and some family features can be identified. These investigators argue that the Native American family can be characterized as having traditional beliefs, practices, and languages and a unique history and life-style.
One of the most important sources of connection and intrinsic worth is the family. Because Native American culture is one in which survival of the individual is synonymous with that of the community, the family holds a prominent place in the lives of Native Americans. The Native American perception of family is universal. Family extends well beyond one's immediate relatives to extended relatives through second cousins, clan members, community members, all living creatures in this world, nature as a whole, and the universe itself. The entire universe is thought of as a family with each member serving a useful and necessary function. Family relationships include much more than the biological connections of the nuclear family. For example, the claiming of nonblood relatives or "fictive kin" as family members is commonly practiced.
Also, a Native American child may live in several different households at various times. Grandparents, aunts, uncles, and community members are all responsible for rearing the children. Nuclear families are important but in times of crisis, support from both the extended family and the tribal community helps people survive. The tribal community acts as a safety net, assuming a great deal of responsibility for the welfare of its individual members. Elders are honored and respected because of the lifetime's worth of wisdom they have acquired and have always played a vital role in the continuance of tribal community by functioning as parent, teacher, community leader, and spiritual guide. Grandparents often hold a unique position helping to pass on cultural values and beliefs to their grandchildren.
More than 200 distinct languages are currently spoken by Native Americans in North America. These languages reflect totally distinct language stocks, many of which are as dissimilar as are English and Chinese. Yet as varied as Native American communities have been, they share the common experience of almost wholesale suppression of the use of their language through policies and practices imposed by various government and educational systems. Some languages have been devastated and obliterated, while others have been less affected and are still being used among contemporary Native American people.
Generally, Native Americans believe that words are powerful and are to be honored and not wasted. There is an emphasis on observant, reflective, and integrative skills which leads to communication patterns that give virtue to silence, listening, nonverbal cues, and learning by example. Native Americans are likely to speak softly (if at all) and take ample time to reflect before responding. Native Americans are not rewarded for asking questions or verbally analyzing situations. Rather, they are expected to learn through patience and observation. Direct eye contact is often seen as a sign of disrespect. As a result of these cultural variables, the Native American client may appear to be passive, uninvolved, and uninterested.
Native Americans differ greatly in their commitment to traditional values and customs. A great diversity exists not only between members of different tribes, but also among members within a single tribe. Cultural commitment among Native Americans has been described in the following four ways (LaFromboise, et. al., 1990):
It is clear that within-group differences have to be considered when working with Native Americans. The nurse should assess the degree of assimilation of the specific client in order to develop a culturally appropriate care plan.
Signs indicative of heritage consistency may include whether the Native American client grew up on or near a reservation, has an extended family orientation, is deeply involved in tribal cultural activities, was educated on or near a reservation, is knowledgeable about or willing to learn about their own culture, and places low priority on materialistic goals. This client is likely to use silence as a sign of respect, have difficulty establishing long-term goals, and feel uncomfortable communicating with non-Indians.
Traditional Native American clients also believe that each individual chooses to make himself/herself well or unwell. If one stays in harmony, keeps all the tribal laws and all the sacred laws, one's spirit will be so strong that negativity will be unable to affect it. On the other hand, if one chooses to let anger, jealousy or self-pity be in control, disharmony will cause the individual to become ill. Once harmony is broken, the spiritual self is weakened and the Individual becomes vulnerable to physical and/or mental illness.
Working with the Native American client starts with acceptance which includes both the client's acceptance of the process and the nurse's acceptance of the client. It is important for the nurse to demonstrate sincere interest and respect for the client. Establishing trustworthiness means being attentive and responsive to the client, giving structure and direction to the process, and displaying respect for culturally relevant values and beliefs. Showing respect could also mean suggesting the possibility of consultation with a traditional healer and whenever possible, linking services between folk medicine and Western medicine. This process would be a clear demonstration of respect for traditional ways while providing culturally appropriate health care plans.
Another way of demonstrating respect is to encourage extended family members to participate in the healing process, and allowing some type of ceremony or ritual that helps restore the client to harmony and balance with the environment.
The following are additional recommendations that can help nurses provide culturally competent care to Native American clients: