Implications for Nursing Care

Establishing trust is the cornerstone of the provider–patient relationship and the foundation of quality health care delivery and outcomes ( ). A health care provider working with the Amish patient and family should begin with a firm handshake, quietly provide an introduction and a greeting of name and purpose, and indicate that it is a pleasure to meet the individual or appreciation that the person has come. If the health care professional can speak a little German or Pennsylvania Dutch, a few words will facilitate the development of trust and provide a commonality around which to relate, especially when talking to children under the age of 5. For example, a nurse with Amish roots contracted with a government agency to draw blood from a group of preselected, multigravida Amish women in a cancer research project. The nurse obtained the blood from all but one woman. A few weeks later, the agency contacted the nurse and questioned the high rate of participation. The nurse explained that he introduced himself in Pennsylvania Dutch, spent 10 to 15 minutes explaining the blood test, and provided his personal background. After this brief discussion, which sometimes included eating popcorn together, the woman extended her arm and the blood was drawn.

Another example, on a pediatric unit where Amish children come for care, the Amish children are well behaved, sometimes stoic, and often shy. However, when the nurse spoke to the children in Pennsylvania Dutch, the response was dramatic. The children were less shy, less fearful, and even smiled. Parents, too, were more at ease, more willing to talk, and more trusting when they felt they had an advocate.

Strategies that can assist in developing trust with the Amish include:

• 1.
  

  Ask questions if unsure of cultural practices.

  
  
• 2.
  

  Approach with a handshake.

  
  
• 3.
  

  Speak slowly and softly.

  
  
• 4.
  

  Have knowledge of Amish customs.

  
  
• 5.
  

  Visit with the individual to get to know the person.

  
  
• 6.
  

  Explain about the cost before doing procedures.

  
  
• 7.
  

  Provide only care that the client desires.

  
  
• 8.
  

  Let family members stay with hospitalized patients.

Amish communicate love and concern by presence. Personal visits, particularly during illness or crisis, are common. In fact, there is almost an expectation to visit a sick family member, close friend, or neighbor. Since Amish do not live in town and hire a van to take them to visit a person in a hospital, they may ask other family or friends to go with them to share the expense. Therefore, Amish patients in a hospital often receive large numbers of visitors at one time. To some Amish patients, the number of visitors is a visible sign of being cared about. To provide culturally competent care for the Amish patient and family, it is important for hospital personnel to adjust rules on numbers of visitors. Visitors do not have to all be in the room at one time to be supportive. Some may go into the room, make their presence known, and withdraw to the hallway in order to allow others to fit into the room. Even having a large number standing in the room is usually not disruptive since volume is kept low. This is particularly true if the patient is gravely ill or near death. This is a time when family members want to be near their loved one. The Amish want to be present in the event that the dying person may have a deathbed message for them (Schwartz, personal communication, 2006).

Implications for Nursing Care

The boundaries between the Amish persons and the outside world are more relaxed when responding to health care professionals. A professional caring for the Amish in the office or hospital can generally follow customary procedures of privacy and professionalism. However, the health care professional should be aware that the Amish may not be as free to show their bodies to their children or spouse. During personal care, the professional should offer the option of family members waiting in another location. Guardedness about personal privacy is relaxing somewhat among the younger generation in some settlements.

The health care professional should be aware that Amish family members care deeply about one another but that this affection is expressed in private, and it is unlikely to be seen in the health care setting. If a husband on a maternity unit appears aloof or even cool, this should not be interpreted as a lack of caring for his wife. Children on a pediatric unit are likely to be subdued and less demonstrative. This is a result of their training to respect adults and elders and to show restraint. In addition, there may be a language barrier, since most Amish children up to the age of 6 do not speak English.

Family Systems and Family Roles

The Amish family is a nuclear family in the traditional sense. It consists of one man and one woman of the same ethnicity and religion who remain married for life. Most Amish get married in their early twenties and are expected to raise large families. An extended family with multiple generations may live in the same house or on the same farm. Grandparents may live in a Dauddy Haus, which may have an enclosed connection to the main house. Families that do not live on a farm will have extended family living next door or in the community. Amish live in a community, where children are expected to care for aging parents. Since aging parents have been part of the household and have helped with childrearing and gardening over the years, it is not difficult for Amish families to continue to care for them in their illness and death.

Amish families are paternal in structure, with the man taking on the roles of breadwinner, head of the family, and disciplinarian. Farming is the traditional occupation for the Amish man. However, with the increased cost of farmland and the high fertility rates, farming is an impossible goal for many. In some larger settlements, increasing numbers of Amish have moved to small farms that cannot support the family. Consequently, even though it is not an Amish value, many men work away from home in occupations such as carpentry, woodworking, construction, and other small industries in the “English” world. This work brings issues that conflict with the primary cultural values, such as the male role model not being at home during the day, not enough meaningful work for the children to do, and the male’s exposure to modern worldly values at work.

Income of Amish families varies widely, not unlike the general population. The young Amish farmer with 5 to 10 children may struggle to provide for basic essentials and have little money for health care expenses. The Amish man working in a factory may receive a good income. Without needing to spend money on manufactured clothes, a car, insurance, education, or entertainment, income may be spent on a nicer home, traveling to visit family, or saved for future needs.

Amish women seldom work outside the home after marriage and having children but may sell quilts or baked goods to help with the family income. A woman is expected to bear children and care for her husband and family. She does her own sewing and preserves garden goods, most of which are grown on the farm or large garden. Some women will work outside the home prior to marriage or may continue to work outside the home if they remain single, which is considered undesirable by the Amish. Amish women see their role as wife and mother. Amish women define health as the ability to care for their husband and family and to participate in community activities without too many aches or pains ( ).

Children are expected to assist with tasks at home at a very early age. By the age of 12 they will have many responsibilities, including caring for the garden and general farm work. Children learn very early that they are an important part of the community. They learn that the community expects them to take on responsibilities and to value and support what is good for the community. Amish children tend to be shy with outsiders.

Individualism is not a virtue in Amish culture. The Amish state that they want to be for others and not for self ( ). A “good Amish person” tries to fit in and not stand out in the community. Pride is seen as a negative attitude. Pride is more often used to describe the opposite of humility, a characteristic God desires from individuals. This does not mean that Amish people cannot develop their gifts or skills but that their talents should be used to benefit the community and not violate the Ordnung . It is not uncommon to see women and girls do farm work. This is particularly true if the older children are girls. However, it is rare to find the Amish male doing housework on a regular basis.

Gender role conflicts, although not obvious to the outsider, may arise in the area of financial management. If the skill of financial management lies with the female, it may cause some internal conflict that will not be obvious to outsiders. The male is usually considered the financial manager, and even for minor medical expenses, the husband needs to be included in the discussion.

The Amish family is clearly defined in structure and roles. The Amish family teaches its values by living the expectations. Amish children are often dressed like their parents and, although they are not expected to be little adults, they are expected to participate in the life of the community as much as they can. A preschooler may be expected to help gather eggs or carry water to others in the field. Sunday is not a workday except for those activities that have to be done, like milking cows. No business is transacted on Sunday. Every other Sunday is church Sunday in the district, and everyone is expected to be present if they are not ill. The Sunday in between is a day of rest, and often the afternoon is used for visiting the ill or friends, or attending church services in another district.

Religious Principles

To understand the Amish culture, it is important to understand the basic Amish religious principles. The Amish strive to incarnate the teachings of Jesus into a voluntary social order ( ). First and foremost, the Amish believe in separation from the world. The Amish believe they are to live in the world but not be conformed to the world (Romans 12:2). It is from this belief that they dress differently and conduct their daily lives with few amenities. This separation also means not marrying an outsider or “English” person and not developing business partnerships with outsiders ( ). The Amish refuse to bear arms or to go to court to bring suit against someone for a wrong. Generally, they choose to move rather than “fight” the state over some issue that violates their religious principles. Obedience to God and humility constitute a pervasive theme in the community, and pride ( hochmut ) is abhorred ( ). Although the Amish value being separated from the predominant society, they will work in it and relate to it. The Amish will not judge other persons, including being on a jury, believing instead that God is the only judge. The Amish will not try to convert outsiders to their ways, although they may try to suggest at times that another’s behavior may not be biblical, as they understand it.

The process of helping its members to live and understand this separateness is found in the Ordnung, the rules and regulations developed by the community ( ). These regulations are decided upon by a group of leaders who present them to the congregation for discussion and response twice a year, just prior to Communion Sunday. This is not a written document but an oral understanding of the beliefs and behaviors of the community. This concept is particularly important for the health care professional to understand because, while similar, not every church district has the same rules and regulations. If an Amish patient is hesitant or not compliant, one could ask if this is not allowed by the Ordnung . The Ordnung classifies what is worldly or sinful within the community and the world. Amish individuals voluntarily submit to the rules and regulations of the Ordnung and allow others to help them avoid emphasizing power, wealth, and status. The Amish try not to stand out or be different in their society but, rather, try to fit into the social order of love and brotherhood within the church district.

The church district is the home church for all members who live within its borders. The functions of the district, besides preaching, are baptisms, marriages, and funerals ( ). Discipline of members is also carried out in the home district. Outside authority and other districts have no jurisdiction over a member. Likewise, a member has no recourse outside the home district. This pertains to church or community matters and not to state or legal matters. The Amish abide by the civil laws unless the law violates a basic principle of Amish belief.

Much of Amish life and behavior has a religious or biblical base. The most important part of Amish life is Gelassenheit, or submission to the will of God. It is based on the words of Jesus, “Not my will but thine be done.” For the Amish, this translates into serving others and giving up individuality and selfishness. It is manifested in many aspects of Amish life, such as:

• •
  

  Personality: reserved, modest, calm, quiet

  
  
• •
  

  Values: submission, obedience, humility, simplicity

  
  
• •
  

  Symbols: dress, horse, carriage, lantern

  
  
• •
  

  Structure: small, informal, local, decentralized

  
  
• •
  

  Ritual: kneeling, foot washing, confession, shunning ( )

Any technology or action that does not uphold the Gelassenheit principles is not allowed and may even be considered sinful. These unwritten decisions are part of the Ordnung . These rules help define what it means to be Amish. As technology changes, new rules may be added, or older ones may change, but the basic rules have stayed in place throughout the history of the Amish. The Ordnung will have many similarities in every church district, but each community will have its own variations on what will be accepted and what will not. The strictness of the rules and the method of enforcement depend on the bishop of each church district. Differences from one church to another may be confusing to outsiders. What is important for the health professional to know is that the Ordnung says very little about the use of modern medicine. The use of a particular medical technology may be discussed at a church meeting twice a year just prior to Communion, where leaders and members debate its ramifications as they understand them. The decision may have less to do with technology than with the rules of Gelassenheit . A bishop will consider a variety of aspects in making a decision. If the bishop decides a medical technology threatens the values or traditions of the Amish, it is banned. However, blood transfusion, organ donation, cardiac bypass surgery, and organ transplantation are generally accepted ( ).

Education

Amish sought the freedom to educate their children in their own private schools. In 1972, there were seven districts in Wisconsin educating their children through eighth grade in their own schools with Amish teachers. Some of the teachers had only a general equivalency diploma. The State of Wisconsin attempted to force these children to attend public schools. Normally, the Amish resist repressive laws for a period of time and try to work things out with the state. However, the Old Order Amish do have a “Steering Committee” made up of bishops, deacons, and laymen that work to negotiate these types of situations with the state and federal government ( ). If the issue cannot be resolved, they have tended to move to a state more tolerant of their views. The Wisconsin situation caught the attention of several outside groups and lawyers, who finally forced a Supreme Court ruling ( ). The Supreme Court ruled in 1972 that imposing mainstream cultural values on the Amish via the public schools would in essence destroy the culture and thus allowed them to maintain their own schools and educational system. In the next 25 years, the number of church districts in Wisconsin more than quadrupled. The number of Amish schools has increased in some settlements since the Supreme Court ruling.

The more conservative Amish districts build their own schools and have their own people teach with state oversight. The Amish are not against good basic education. Many Amish pupils test above the norm in their states ( ). The mixed-grade, one-room schoolhouses, which are typical of pre-1945 rural America, are preferred because of the importance of transmitting Amish values and because they are more amenable to local control (Wenger & Wenger, 1998). reported that in 1948 the Amish began looking at secular education and concluded that some of the curriculum was contrary to Amish beliefs. Materials that supported the Amish ways of life were selected. Many books used in many Amish schools have copyright dates of the 1960s and earlier; thus, up-to-date science and health information is not present. Rather, children are taught the importance of discipline, of helping each other, of obedience and truthfulness, and of the idea that what is good for the group is also good for the individual. Children are taught how to live and to prepare for death in the Amish tradition.

Public school education is perceived as a threat to the culture. The Amish are concerned about the time required to bus students out of their home communities and the subjects that are viewed as “unnecessary,” such as advanced math and computer technology, which have little relevance to the Amish tradition ( ). They are concerned with the instruction in a value system that is antithetical to the Amish way of life in which individual achievement and competition are promoted ( ). They have a tendency to shun higher education because they know that those who complete high school leave the church and become “English.” The emphasis is on practical education or education for the simpler life. Consequently, few Amish complete high school, and almost none has a college education.

In more heavily populated settlements, more Amish children attend public school. Most are taken out of school at age 16. Many public school districts that have a number of Amish children attempt to develop policies, course requirements, and student activities that the Amish will not find problematic.

Amish Youth

Amish youth are permitted to experience the world in their late teens; this is known as Rumspringa ( ). Some allowances are made for dressing more “English,” perhaps having a car (which some may park at an “English” neighbor’s house rather than at home), or participating in typical activities experienced by “English” teenagers. The message is clear that such activities are in violation of community rules and sometimes even state law, but since the Amish youth are not baptized members yet, they are not told to stop the behavior or banned from the church. The Amish youth know that this way of life must be left behind when they decide to be baptized and join the church. Most Amish youth who participate in such activities know these are a violation of community values but have little intention or desire to leave the community. The Amish community and bishops accept this behavior as “sowing wild oats” and tend not to make a big issue out of it, because it allows these youth to put it away later and come back to the church. A health care professional should not be confused when caring for a youth who looks “English” but has Amish values and ideas associated with the traditional Amish. Considering the enticements of the culture around them, it is remarkable that 85% of Amish youth choose to join the church and to maintain the values they have been taught throughout adult life ( ; Wenger & Wenger, 1998).

The Amish and the State

The Amish are not a financial liability to the state ( ). There is little or no unemployment, virtually no divorce, and very little delinquency among its youth. As a group they are trustworthy and hard workers, and they do not join unions, which makes them desirable as employees ( ; ). The Amish are law abiding (unless a law violates the Ordnung ), do not bring suit for personal gain against anyone, and are cooperative and compassionate, as an “English” neighbor discovered when the whole community showed up to help rebuild a barn that had burned ( ).

Implications for Nursing Care

The health care professional should be aware that some health care decisions may be based on the Ordnung . Some health care professionals think that Amish do not believe in or approve of immunizations. There are a few districts where this is true; however, immunization rejection by an Amish person is more often based on ignorance, cost, or some other rationale. Thus, it would be appropriate for a health professional to discuss the pros and cons for rejecting a health treatment with an Amish person to see if it is based on the Ordnung or due to some other belief or situation. Amish are aware of the religious waivers one can use to avoid immunizations and may use that route when their refusal may actually be an issue of cost. Husbands, who often accompany their wives and children when seeking health care, are the gatekeepers for the family’s health care decisions ( ).

Birth control is forbidden in most church districts. However, with increasing numbers of Amish moving out of farm settings, many Amish are starting to consider the number of children a family should have. Farms provided a natural environment to teach the work ethic that is not available in a nonfarm setting. Decisions or rationales related to birth control are not for public discussion. The methods used for birth control may include condoms, withdrawal, or abstinence. The Amish have also discovered the limitations of these methods, so some look to other options. One physician in northern Indiana reported to the author that he performed a number of vasectomies on Amish men on Friday afternoons. The physician felt the procedure was done without the sanction or knowledge of the Amish bishops because he was located out of the mainstream Amish community. The health care professional should approach the question of birth control with caution because Amish generally reject it. However, if the nurse senses that the Amish patient wants to discuss birth control, the advantages and disadvantages of options should be offered ( ).

Health care interventions need to be designed for the Amish in a culturally sensitive manner that considers the values and needs of the group. For example, the state health department asked a nurse to assist in an intervention in a settlement where several Amish children had died from pertussis. The state health department presenters gave explanations to the bishops on immunization theory and how it protects children by giving a controlled disease so the body could build its antibodies without causing major harm. The presenters stressed that children did not have to die from this disease if immunized. This was an important point because Amish desire children and see them as a gift from God. The death of a child is seen as a great loss. After a discussion time with the bishops over a full-course lunch, it became clear that the issue was not refusing to get immunizations because of Ordnung but more the cost of getting everyone in a family with 4 to 10 children immunized, since free immunizations were not available. A proposal finally emerged. The state would bring a team to their schoolhouse and charge a fair price for the vaccine, and the bishops would promote the event in the churches. Several weeks later, the immunizations took place.

It is important for the health care professional to appreciate the value of the Amish in placing others in the context of family, relatives, and community. In the hospital, it is not unusual for an Amish person to stop a person in the hall who is wearing distinctive Amish dress, shake hands with an Amish stranger, and ask in Pennsylvania Dutch, “Who are you?” Within minutes, they may discover that they are distant relatives or have a mutual acquaintance. At the same time health care professionals need to be aware of the privacy of the patient and not divulge patient information just because the inquirer is Amish. Amish women especially are very private and do not want private matters to become public even in the community in which they live ( ).

The simple question “Who are you?” is a powerful networking tool that the “English” may not understand in dealing with the Amish. For example, a CEO of a hospital was to meet with an Amish leader to finalize an agreement to have the leader sign a contract or come to an understanding of how payment of a hospital bill would be handled if one of their members should use the CEO’s facility. The CEO wanted to proceed as quickly and efficiently as possible, which is not an Amish value. When the CEO started pushing for some sort of an agreement, the Amish person pulled back and said, “I don’t even know you.” The CEO was stunned. This did not mean that the Amish man needed to know what degrees and credentials the CEO had, because those have little meaning to the Amish community. Rather the statement meant that the Amish person wanted to know about integrity in business dealings. An evaluation of trustworthiness will be established by determining “who you are.” It is imperative for all health care workers to work on building trust by being open and honest with the Amish patient ( ).

Birthing centers have been established to respond to the needs of the Amish. Financing may be largely provided by the Amish community ( ). The Wall Street Journal reported negotiations between hospitals and religious communities to reduce cost of health care to Amish and Mennonites ( ).

The social support in the Amish community is evident in care of the elderly. Amish are seldom found in a nursing home. An Amish person may be sent home from a hospital sooner than other patients with like diagnoses and treatments because of the desire of the family to have the sick individual at home where care can be provided and because of the desire to lessen the expense of the hospital ( ). Most Amish persons will not have traditional insurance or Medicare unless they have worked in a factory. The health care professional may wonder how Amish can afford to pay large medical and hospital bills without private insurance. In some areas the Amish community has contracted with health care providers who will discount their bills by 20% or more since they know the bill will be paid in a timely fashion. Several hospitals have developed a special rate for a normal delivery in obstetrics if the bill is paid prior to the hospitalization. Some Amish have what is called “Amish Aid,” or a mutual insurance for large hospital bills or losses of any kind, although they do not call it “insurance.” When a hospital bill is received that a family cannot pay, the church leaders in the district will take responsibility for starting the mutual insurance process. If it is not a large bill, the district may take care of it by asking members to contribute. If it is a larger bill, it is divided up among some or all the districts in a settlement or even several settlements. On a Sunday morning a leader of each district will announce each family’s share of a certain hospital bill. Individuals will give this person cash, which he will put in his pocket to count when he gets home. If not enough money is collected for a district’s share, it will be announced again at the next church meeting until the sum has been collected. These needs may also be announced in The Budget (an Amish newspaper) with a request to shower the person or family with cards or prayers ( The ). Some church districts and settlements have gone to fund-raising activities such as auctions of donated items or meals (for example, a haystack supper) (see Box 29-1 for the recipe). The added benefit of these activities is that non-Amish family and friends can participate in the financial needs of a particular person. Some settlements are seeing that the high cost of health care is a major concern. Some settlements have started a hospital insurance fund that individuals can voluntarily join by paying a certain fee into the fund regularly, which makes them eligible to draw upon the fund in case of need ( ). Some Amish groups are collaborating with local health care agencies to ensure lower health care costs.

Box 29-1

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