A Portrait of a Native American Tribe 1

Running Head: A PORTRAIT OF A NATIVE AMERICAN TRIBE

A Portrait of a Native American Tribe: Nursing Care for the Navajos

Maria Josefina C. Wallace

National University
 A Portrait of a Native American Tribe 2

A Portrait of a Native American Tribe: Nursing Care for the Navajos

Introduction

Nurses care for the whole person. Because nursing care is truly holistic, then culture must

be an integral part of the nursing process. Culturally competent care is achieved when the

essence of caring is expressed differently in different cultures in which a patient’s view about his

or her own culture is more important than the nurse’s assumption about it (Wikberg & Eriksson,

2008). Combining the Human Caring Theory and Transcultural Theory is an expanded

dimension of nursing care that joins the ego-less state of caritas and love (Alligood, 2010) with a

culture-specific and universal practice aimed at helping the patient to face unfavorable human

conditions, illness or death (Leininger, 2008).

This paper will discuss the concept of cultural competence by describing techniques or

methods that can be used in the delivery of health care services to the Navajo tribe, an American

ancestry. Using the Giger and Davidhizar Transcultural Assessment Model to understand the

Navajo culture, this paper will identify ways in which the Navajo culture influences its folk and

health-seeking behaviors. Ultimately, this paper describes the Navajo people’s way of life in the

context of the six phenomena – communication, space, social organization, time orientation,

environmental control and biological variations. Implications for nursing care will be interjected

within each phenomena in an attempt to provide a complementary and harmonious blend of the

Navajo tribe’s beliefs, attitudes and values with Western health care practices to help achieve a

holistic and yet culture-specific nursing care for the Navajos.

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Health Practices in the Navajo Culture and the Western Perspective

A Glimpse of Navajo History

The Navajos live in what is now northwestern New Mexico and northeastern Arizona.

They constitute the second largest Native American tribe in the United States with the first being

the Cherokees ("Sierra Service Project," 2011). In their own language, they call themselves DinE

which means “the people” and their land, DinE Bikeyah or the “people’s country.” The Navajo

people lived freely on the land of their forefathers, located between the four mountains: to the

east is Mount Blanca in Colorado, to the South is Mount Taylor in New Mexico, to the West is

the San Francisco Peak in Arizona and to the North is Mount Hesperus in Colorado (Giger &

Davidhizar, 2008). For the Navajo people, these four mountains are sacred because they are

historically considered the cardinal boundary peaks surrounding the Navajo county. To this day,

the Navajos believe that the Four Sacred Mountains were gifts from the “Holy People” that their

traditions, prayers, songs and sacred trust are embodied in these mountains (Giger & Davidhizar,

2008). In 1864, one of the most significant periods of Navajo history occurred when more than

9000 Navajos were forced to journey to Fort Summer on the Bosque Redondo Reservation in

what is now New Mexico. During this long journey, more than 2000 Navajo men, women and

children died of respiratory tract diseases, gastrointestinal disorders, and exhaustion (Giger &

Davidhizar, 2008). This event paved the way to the signing of a treaty with the United States of

America in 1868 after which the Navajos moved progressively in the direction of the Four

Sacred Mountains where the Navajo people began their lives in self-determination, self-

governance, and self-actualization.

 A Portrait of a Native American Tribe 4

The Navajo people developed a diversified economy early on raising sheep for livestock

as the primary element of their economy, followed by farming corn (Csordas, 2002). In the

twentieth century, livestock and farming were supplemented by wage labor in railroad

construction and mining of coal and uranium. Navajo society is traditionally organized around a

system of exogamous matrilineal clans (Csordas, 2002), wherein families are traced through the

women’s line of descent. Today there are 500 Indian tribes in the United States of America, the

Navajo people having a population of 300,000 ("Sierra Service Project," 2011) who live within

the boundaries of what is known the Navajo Nation. The Navajo Nation covers 27,000 square

miles in the states of Arizona, New Mexico and Utah ("Sierra Service Project," 2011). A high

unemployment rate, and hence low income, has resulted in very high Poverty Rate on the Navajo

Nation. The ACS 2007 found that 36.76% of the Navajo individuals were living below poverty

level. The numbers for Arizona, New Mexico and Utah were 14.16%; 18.13% and 9.65%

respectively (Division of Economic Development, 2007).

Three Religious Navajo Healings

Religion and spirituality are inseparable from the health care and healing of the Navajo

people. While healing is the central theme of the Navajo religion, the sacred is the central

element in Navajo medicine (Csordas, 2002). Just as the Navajos orient themselves

geographically within the cardinal boundary peaks of the Four Sacred Mountains, they orient

themselves medically within the interactions of four modes of healing: conventional

biomedicine, Traditional Navajo healing, Native American Church (NAC) healing, and Navajo

Christian faith healing (Csordas, 2002). Navajo religious healing has three principal varieties: the

Traditional Navajo Healing is that of the hatali, who performs intricate chants and sand-paintings

(Csordas, 2002), and of the diagnostician who works by methods such as hand-trembling, in
 A Portrait of a Native American Tribe 5

which the diagnostician passes his or her hand over the body of patient while praying to a deity

(Cozort, n.d.); the NAC healing is that of the old man, who prays at his earthen altar or fireplace

and administers sacramental peyote (Csordas, 2002); and Christian faith healing is that of the

independent Navajo Pentecostal preacher, with his revival meetings and lying on of hands, and

of the Catholic Charismatic prayer group, with its communal integration of Navajo and Roman

Catholic practices (Csordas, 2002). Schneider and DeHaven (2003) explained in their article

from the Perspectives in Biology and Medicine that, “traditional Navajo Medicine Man or hatali

offers an intricate perspective on healing... as they sing the world back into congruence, into

being, into its original and emergent perfection...this power forms the basis of all Navajo healing

ceremonies, underpinning the healing encounter itself.” (Schneider & DeHaven, 2003). The

hatali must be of significant intelligence and possess the ability to remember hundreds of songs

and chanting acts and have religious sensibility. The Medicine Man in his chants portrays a battle

involving a community ridding itself of suffering and striving toward harmony (Schneider &

DeHaven, 2003).

Concepts of Health and Illness Compared

The Navajo purpose of life is to grow old in beauty or hozho, and to live in harmony

between oneself and one’s environment, including all the living things that inhabit it; these living

things may be a human being, an animal or a spirit. Harmony with nature provides meaning in

life, and the Navajos’ strength come from their inner selves and from a balanced relationship

with their surroundings (Schneider & DeHaven, 2003). The Traditional Navajo healers

emphasize a person’s relationship with nature where illness is only a special case of the tendency

toward entropy and error. Navajos believe that illness occurs because an individual acts

incorrectly, or acts with the wrong motives such as violence, drunkenness, and disrespect for the
 A Portrait of a Native American Tribe 6

elders thus leaving one open to disease (Cozort, n.d.). Illness itself can be caused by violating

taboos, by contact with lightning or outsiders, or by ghosts or witchcraft.

From the Western perspective, Watson’s notion of life is based on the concept of human

beings as embodied spirits. Health is the unity and harmony within the body of the patient, mind

and soul, and a harmony between self and others viewed as consciousness and a human-

environmental energy field (Alligood, 2010). Illness from King’s theory of Goal Attainment is

a subjective turmoil or disharmony in one’s health, within its functional or holistic state

(Alligood, 2010) and Levine’s Conservation Model expresses illness as an adaptation to harmful

environmental forces (Alligood, 2010). Additionally, the naturalistic explanation of illness in the

Western World assumes that illness is only due to impersonal, mechanistic causes in nature that

can be potentially understood and cured by the application of the scientific method of discovery

(O’Neil, 2008).

Processes of Diagnosis and Healing Compared

In any healthcare provider-patient relationship in the Western World, both parties have

one goal in mind – to find cure for the patient’s illness, if not to minimize it or for prevention. In

this process called diagnosis, the health care provider must determine the nature of the illness

and manage it accordingly. When a patient is ill, he or she reports the primary symptoms to the

health care provider. Because every symptom has multiple causes, the physician interviews the

patient to narrow the possibilities. Initial questions for the patient usually pertain to any

associated symptoms; past medical conditions and family medical history that may be related to

the illness; and habits related to work and leisure, all of which identify risk factors for certain

conditions. To further narrow the differential diagnosis, diagnostics tests such as blood tests,
 A Portrait of a Native American Tribe 7

pathological analyses of biopsy samples, and imaging studies may be performed to rule out other

possibilities (Lee, 2009). Ultimately, based on the available clinical information, the physician

summarizes the most likely diagnosis and its rationale, to formulate a plan that involves further

diagnostic testing or treatment.

All of the above require a thought process to interpret information from the patient and

evaluate the possible causes for the illness. To explain any clinical manifestation, a healthcare

provider works backward from the symptoms and signs to the possible conditions (Lee, 2009).

The process is very methodical and detailed, requiring cooperation between the physician and the

patient for best results.

For the Navajo, physical and psychological illnesses are thought of as monsters to be

slain, as they are chanted in the Monsterway Chant, one of Navajo’s most notable ceremonies

(Schneider & DeHaven, 2003). The chants last from five to nine days, in which the patient

typically presents to a traditional healer, asks for assistance, and awaits instructions while he or

she remains silent. The Navajo medicine man asks a few questions from the patient,

acknowledges his or her pain and sufferings, and uses a variety of ways in finding the cause of

disharmony (Schneider & DeHaven, 2003). The medicine man uses three methods for diagnosis:

“stargazing” in which he looks at the stars either directly or through a crystal; “listening” as he

appreciates all heard messages about the patient’s distress; and “hand trembling” involving an

involuntary motion of the hand closely to the patient (Schneider & DeHaven, 2003). A ceremony

is then performed by the medicine man to expel the cause of illness.

The restoration of harmony in healing is a communal process for the Navajo – the power

of the medicine man is key as are the contribution of those witnessing the chant and the thoughts
 A Portrait of a Native American Tribe 8

of others miles away (Schneider & DeHaven, 2003). Not only is the harmony of both the

individual and community restored from the healing ceremonies but, also an aspect of

communication with a nonhuman community that today’s conventional thinking cannot seem to

comprehend nor accommodate (Csordas, 2002). To the Navajo people, suffering from an illness

is parallel to that of the person, the community and the nonhuman world.

From both perspectives, patients need to be able to make sense of their illness and place

them in the context of their lives. Illness disrupts the patient’s harmony with self and

surroundings and adjustments need to be made so that the patient can better understand the

implications of the illness (Schneider & Dehaven, 2003).Taken as a whole, traditional Navajo

healing has elements which are consistent with the phenomenological view of medical practice.

Applying the Transcultural Model and the Culturally-Competent Nurse

To move beyond resistance, a competent nurse who is cross-culturally skillful learns first

about his or her own culture. This country is a melting pot of cultures from other parts of the

world and I for one, have my own. I am a Filipino-American, and I understand my culture as a

baseline for cross-examining others but, I also learn how others see me in my culture. In this

country that I call home, people represent multiple ethnic and cultural backgrounds who share a

common subculture that I will be referring to in the following discussion as the “American

culture.” The Navajos while being Americans have a distinct culture of their own; I will be

differentiating between the two.

Developed in 1991, the Transcultural Assessment model allows me to focus on the six

areas of cultural phenomena that will help me gain an understanding of the Navajo patient's

cultural perspective and the impact it has on health. The model emphasizes that although all
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cultures have unique and distinctive characteristics, all cultures have the same basic

organizational factors. Giger and Davidhizar (2008) have identified six phenomena that vary

among cultural groups, and are discussed next:

Communication. Because communication is the means by which culture is transmitted

and preserved, when the nurse assesses this phenomena, his or her assessment should consider

the dialect, style, volume including silence, touch, emotional tone and kinetics (Tortumluoglu,

january-april 2006). Athapaskan is the Navajo official language and it involves tonal speech in

which pitch is of great importance (Giger & Davidhizar, 2008). In the Navajo language, position

is defined as a withdrawal motion so when a Navajo speaks, “I moved into my clothes,” while

the English speaker would say “I dressed.” Americans are direct in their style of communication

attributed to the way they think – very linear who value efficiency in most things, including

conversation such as, “Get to the point.” (Carteret, 2008) Athapaskan does not always have an

equivalent single word for an English word; it uses instead a description of all occurrences

affecting what is actually being said (Giger & Davidhizar, 2008). As such, I must remember that

what is being said must be interpreted in approximation in all the stages of the Nursing Process.

When I am being greeted by a Navajo patient, I must expect a light touch of the hand from him

or her because this is his or her practice, instead of shaking hands as the Americans would

normally do (Giger & Davidhizar, 2008).

Space. All communication occurs in the context of space. It is the distance between

individuals when they interact. The Navajo people do not believe in imaginary space, rather

space is a real concept just as they would find it in a room or a house (Giger & Davidhizar,

2008). The traditional Navajo dwelling called hooghan is surrounded with traditions and

superstitions such as the need to seal the entry of the hooghan as a warning for some Navajo
 A Portrait of a Native American Tribe 10

folks to stay away due to an illness from within. The hooghan is central to the Navajo culture

that all healing ceremonies are performed in it. In the American culture, space is used to classify

people and activities, such as “the corner bakery” or “the corner office.” Propinquity is important

among the Americans, as they also depend on architectural features as shields to their egos. For

example, when an American wishes to be alone, he or she simply goes into a room and shuts the

door (Hall, n.d.). It is important for me to familiarize my Navajo patient with the space provided

during hospitalization or in smaller facilities where space is limited because space has no

imaginary boundaries to my Navajo patient; he or she may not easily adapt to unfamiliar places.

The unfamiliarity is particularly true when the Navajo patient is hospitalized outside the Indian

Reservation.

Time Orientation. Human life exists in a three-point range that includes past, present and

future according to the cultural interpretation of time. The Navajo people are primarily viewed as

present-time oriented and as being on a continuum, with no beginning and no end (Giger &

Davidhizar, 2008). Because of this view, the Navajo patient may be late for appointments as they

are less concerned about planning to be on time or may neglect preventive health care measures.

Americans battle with time on a daily basis – they talk about saving or wasting time, managing

time and beating the clock. Americans’ adversarial relationship with time led to the invention of

fast-food and drive-thru, day-timers, multi-tasking, and now, even banks and pharmacies have

drive-thru services (Carteret, 2008). In a healthcare setting, it is important for me to take into

account that the Navajo patient’s time is casual, present-time oriented and some needs must be

accomplished in a present-time frame. For example, I should be very thorough when planning for

future crucial tasks for the Navajo patient such as taking medications. Because of their present-
 A Portrait of a Native American Tribe 11

time orientation, the Navajo patient tends to take meals in an irregular pattern which may

influence the effects of medications that need to be taken with meals.

Social Organization. The social environment in which people grow up and live plays an

essential role in their cultural development and identification (Tortumluoglu, january-april 2006).

The Navajo culture is extremely family oriented in a matriarchal society where the husband

makes his home with his wife’s relatives (Giger & Davidhizar, 2008). The mother in a traditional

Navajo nuclear family is the housekeeper; the husband takes charge of activities outside the

household to keep and maintain the family and the children help both parents. Some Navajo

marriages are still arranged and in any case, marriage and family are the foundations of Navajo

life. Americans value self-sufficiency where success without depending on others shows

supreme self-determination, self-reliance, and self-confidence (Carteret, 2008). One aspect of

American culture is individualism in which one’s interests should take precedence over those of

the social group. Although it is true that the family is the basic unit in American society, the

individual is paramount; everyone wants to be at the top of a hierarchy (Carteret, 2008). As a

nurse, knowing that the Navajo patient believes that family members are responsible for each

other, I should expect for many of their relatives to come to the hospital to care for the patient. I

will ensure that my discharge planning for the Navajo patient includes the family in the areas of

patient-teachings, the flexibility in scheduling medical appointments and that the referrals to

appropriate resources are sensitive to family-centered care. Whenever possible, I would arrange

for a private room when there is a need for hospitalization to provide space for the family and

relatives.
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Environmental Control. This is the ability of the person to control nature, health

practices, values, and definitions of health and illness. Through environmental control, a patient's

perception about health and illness is assessed, as well as exploring his preferences in seeking

health care (Giger & Davidhizar, 2008). The Navajo folks are perceived as having an external

locus of control, in which they perceive illness as a disharmony with other forces and that

medicine is only capable of relieving the symptoms rather than curing the disease. They are also

likely to look for naturalistic solutions in the form of herbs for example, to resolve or cure a

cancerous condition (Tortumluoglu, january-april 2006). Among Americans, glorification of the

human being’s ability to use, control and master their environment is dominant. For example,

when an illness occurs, the underlying cause or causes are examined and explained in a rational

and reflective way rather than just maintaining the status quo (Giger & Davidhizar, 2008).

Because the Navajo cultural values are placed on folk remedies, the risk of delaying treatment is

high. To exemplify, when a sick Navajo child whose parents strongly believe in home remedies

and herbal cures is presented for care, I should try to determine if an alternative therapy has

already been used. If it has already been considered and deemed productive, I will try to

incorporate that alternative therapy into the treatment plan in a culturally sensitive manner (Giger

& Davidhizar, 2008).

Biological variations. According to Giger and Davidhizar (2008), a direct relationship

exists between race and body structure, skin color, other physical characteristics such as genetic

variations, susceptibility to disease, nutritional preferences and deficiencies. One third of the

American Indian population is in absolute poverty (Giger & Davidhizar, 2008) and the Navajo

population is no exception. Poverty has resulted in many illnesses and diseases that are related to
 A Portrait of a Native American Tribe 13

poor living conditions and malnutrition making the Navajos at risk for tuberculosis, maternal and

infant deaths, diabetes and malnutrition (Giger & Davidhizar, 2008). Mongolian spots are

remnants of a pigmentation produced by melanocytes, and are obvious in eighty percent of

American Indians, including the Navajos. Therefore, the nurse will find melanosomes that are

incorporated singly in the skin-color of the Navajo patient when inspected during a physical

health assessment (Giger & Davidhizar, 2008). Additionally, the Navajos are perceived to have

pronounced cheek bones, straight and coarse black hair, reddish-brown skin color, and little body

hair (Schneider & DeHaven, 2003). Biological variation in the American cultural perspective

cannot be consistent across space, partly because of prehistoric and historic migrations; such

migrations were considerably mixture between groups that were different in their patterns of

biological variation (Wienker, 2001). The article published online by Wienker stated that,

“Biological variations are spread far back into our past and because they have been taking place

for so many millennia, the net result is an extremely muddled pattern of human biological

diversity across the United States’ geographical space today.” (Wienker, 2001) For example, the

Hispanic category includes Cubans, Mexican and Puerto Ricans. Furthermore, in Cuba, almost

half the population has significant African ancestry (Wienker, 2001); the Mexicans in contrast

have little African ancestry but, predominantly Spanish and American-Indians; lastly, the Puerto

Rican gene pool is constituted of significant amounts of Spanish, American-Indian and African

ancestry (Wienker, 2001). To exemplify, because ethnicity also appears to be an important

factor in the incidence of tuberculosis among the Navajos, as a nurse, care for my Navajo patient

would include significant teachings about how the disease is spread and explain the symptoms of

the disease as well as preventions using the simplest, straightforward and easy-to-understand

language (Giger & Davidhizar, 2008).

 A Portrait of a Native American Tribe 14

Conclusion

This paper has described and introduced the culture of the Navajos; has compared and

contrasted that with the typical American culture using the Giger and Davidhizar Transcultural

Assessment Model in the context of the six cultural phenomenons – communication, time, space,

social organization, environmental control and biological variations. In doing so, this paper has

achieved its intent to help the nurse gain awareness in the perception of self around the cultural

experience as it provides him or her baseline for comparison enabling the nurse to observe

without leaping to judgment. As they strive to provide culturally sensitive care to the Navajo

folks, the nurses must recognize how they and their Navajo patients are culturally similar as well

as different. It would be difficult to reconcile the differences between contemporary and modern

technology in health care typical of the American culture and traditional Navajo healers’ Navajo

mythology but, leaving the differences aside, it is possible for the nurse to provide optimal,

holistic and culturally-sensitive care while the Navajo patient finds encouragement to care for

himself or herself, and others within a familiar, supportive, and meaningful cultural context.

Hopefully, this paper has expanded the cultural care negotiation in the realms of

Leininger’s Diversity and Universality Theory that even though Navajo healing can be a

religious and private issue, Navajo patients are willing to discuss with nurses their own

traditional beliefs if asked in a sensitive manner. Culture care negotiation in Leininger’s theory

of Transcultural Nursing Care refers to the “creative nursing actions that help people adapt to or

negotiate with others in the healthcare community in an effort to attain the shared goal of an

optimal health outcome” for the Navajo patient (Leininger, 2008).

 A Portrait of a Native American Tribe 15

In conclusion, in culturally competent nursing care, “the patient’s acculturation affects

caring, because the more integrated the patient is in the dominant culture, the easier it is to accept

nursing care, and vice versa.” (Wikberg & Eriksson, 2008)

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