After reading this chapter, the nurse will be able to:
Identify ways in which the Navajo culture influences Navajo individuals and health-seeking behaviors.
Recognize physical and biological variances that exist in and across Navajo groups to provide culturally appropriate care.
Develop a sensitivity and understanding for communication differences as evidenced within and across Navajo groups to avoid stereotyping and to provide culturally appropriate nursing care.
Develop a sensitivity and understanding for psychological phenomena that influence the functioning of a Navajo when nursing care is being provided.
Describe the influence of traditional Navajo folk medicine and the relationship to health-seeking behaviors.
Overview of the Navajos
Archeological evidence places Navajos in the Gobernador Canyon area of northwestern New Mexico by the late 1400s or early 1500s. By the early 1600s, some Navajos had migrated as far as the Black Mesa country of northern Arizona ( ). The first written historical observations of the Navajos have been attributed to Arate Salmerón (1626) and Father Benavides (1630).
According to (Schwartz, 2004; ), the various Pueblo peoples exerted a tremendous influence on the evolution of the Navajo culture in the new region. There is historical evidence indicating that the Navajos and Pueblos were at times foes. However, suggested a number of instances when Navajo and Pueblo villages allied themselves against the Spanish and other outside groups. Schwartz (2004) and concluded that the Navajos and the Pueblos existed together in a relationship that was more peaceful than hostile. Regardless of whether the Pueblos and the Navajos lived peacefully, the Pueblos probably did influence change in the Navajo lifestyle in some critical ways. For example, the Navajos have a matrilineal clan system that still exists today and dictates that a Navajo inherits the clan and thus the lineage from the mother ( ; Schwartz, 2004). The implication is that people from the same clan are considered relatives with varying responsibilities to one another.
For the western Pueblos, the clan traditions were strong, and it is probable that they influenced the Navajos in the direction of clan formation ( ). In addition, the Pueblo people were sedentary and had agricultural ways that undoubtedly also had some effect on the Navajos. As a consequence of these influences, the Navajos gradually adopted a way of life that was significantly less nomadic, with less emphasis on hunting than that of other Apachean groups. Seemingly, the Navajos learned trades such as weaving, pottery making, silversmithing, and agriculture from the Pueblo people en route to the Southwest. According to , the Navajos credit “Spiderwoman” with their instruction in weaving. Differences existed in that Pueblo men traditionally were weavers, whereas Navajo men rarely became weavers.
During the sixteenth, seventeenth, and eighteenth centuries, the Navajo people underwent tremendous expansion, cultural acquisition, and social change. According to , the Navajos have always had a great capacity to absorb and elaborate on cultural traits adopted from other people. For example, the Pueblo weaving tradition is responsible for producing the Navajo blanket, which is unmistakably the product of the Diné (the Navajo word for people ). The language, although distinctively Navajo (from the entirely different Athapaskan family of languages), was learned by other Indians; however, few Navajos attempted to master a foreign tongue ( ). The Navajo people lived freely on the land of their forefathers, located between the four sacred mountains: Mount Blanca (Colorado) to the east, Mount Taylor (New Mexico) to the south, San Francisco Peak (Arizona) to the west, and Mount Hesperus (Colorado) to the north. Four directional colors were associated with the four sacred mountains: white with Mount Blanca, blue with Mount Taylor, yellow with San Francisco Peak, and black with Mount Hesperus. To understand the history of the Navajo people, it is important to understand the significance of the four sacred mountains, which historically were considered the cardinal boundary peaks surrounding the Navajo country. Even today, Navajo people believe that the four sacred mountains were gifts from the “Holy People” ( diyín dine ` é , or haashch ` ééh dine ` é ); therefore, traditions, prayers, songs, and sacred trust are embodied in these mountains ( ; Schwartz, 2004; ).
Perhaps one of the most significant periods of Navajo history occurred during 1864, when more than 9000 Navajo people were captured in what is now Arizona and forced to journey to Fort Sumner on the Bosque Redondo Reservation in what is now New Mexico. During this long journey (known in Navajo history as the “long walk”) and internment at Fort Sumner, more than 2000 Navajo men, women, and children died of respiratory tract diseases, gastrointestinal disorders, and exhaustion.
During May 1868, the fourth year of their forced internment, the Navajos’ elected leader, Chief Barboncito, told a Washington delegation appointed by President Andrew Johnson, “I hope to God you will not ask me to go to any other country except my own.” In speaking these words, Chief Barboncito expressed the feelings, beliefs, traditions, and desires of the Navajo people. On May 28, 1868, the United States of America and the Navajo tribe entered into a treaty that was ratified on August 12, 1868, by President Andrew Johnson ( ; Schwartz, 2004; ).
After the signing of the 1868 treaty, the Navajos moved progressively in the direction of the Four Sacred Mountains. Gradual as it might have seemed, the call from the Four Sacred Mountains for the return to Navajo ways reflected the futuristic response of self-determination, self-governance, and self-actualization ( ; ). Although the treaty signed at Fort Sumner was not the first treaty but the eighth treaty made between the Navajo people and the United States in 22 years, it was historically significant because it led to their release from Fort Sumner and to the establishment of their first reservation at Fort Defiance, Arizona. (At that time Arizona was a separate territory; it became the forty-eighth state in 1912.) After the Navajo people were released from their internment at Fort Sumner, they began to develop a diversified economy. For the Navajo, raising livestock was an important element of the economy but not the only element. From early and later historical accounts, it appears that the Navajos have always been perceived as great farmers. A reemerging question about the Navajo people concerns why they traditionally needed such a diverse economy; another reemerging question concerns why livestock took on a more essential role within the Navajo economy. The answers to these questions seemingly overlap and are mutually reinforcing: for the Navajo people, a diversified economy made more thorough and efficient use of the different opportunities provided by various soils, altitudes, and vegetations.
Three different climatic zones exist in the area in which the Navajo people live. The humid, or mountain, zones account for roughly 8% of the total Navajo area; the mesas and high plains, with their intermediate steppe climate, account for roughly 37% of the Navajo area; and the comparatively warm desert regions account for roughly 55% of the Navajo area. Winter temperatures in these regions range from an average minimum of 4° to 15° F in the humid zone, to 10° to 25° F in the steppe zone, to 11° to 30° F in the desert zone. Summer temperatures in these regions range from an average maximum of 70° to 80° F in the humid zone, to 80° to 88° F in the steppe zone, to 100° F or higher in the desert. The average rainfall in all three areas is concentrated in the late summer period, which extends from July to September, with great variation in amount within each zone. The desert and humid zones each receive an additional 41% of precipitation in the form of winter snow.
The soils in the Navajo region may be classified as excellent, good, or fair in terms of runoff, grass-producing ability, and erosion. Only about one third of the area is considered excellent or good in terms of soil productivity, and about 15% of the soil is unproductive, with little vegetation cover. The vegetation includes grassland, meadows, sagebrush, browse (shrub), and woodland (which is inaccessible and barren in some places). More Navajo land is covered with coniferous timber than with sagebrush ( ).
It was believed that the conflicts between the Navajos and their neighbors were contributing factors to their economic diversification. For example, historical accounts suggest that as raiding by and against the Navajo people grew in intensity, it consequently complicated agricultural pursuits and led to an increased need for mobility. In addition, the steady growth of the Navajo population figured greatly in the economic diversification: as the Navajo tribe grew in number, so did the quantity of livestock. Two principal periods of growth occurred in the Navajo tribe. The first period came in the last years of the eighteenth century and in the early years of the nineteenth century, before the White American campaign against the Navajos. The second principal period of growth followed the Navajo return from Bosque Redondo. It was during the first period of expansion that livestock was established as an economically important commodity ( ; ).
Life Today among the Navajos
The spectacular growth of the Navajo population began during the post–Fort Sumner era. In 1870 the Navajo population numbered 15,000 ( ; ). By 1900 the Navajo population had grown to 21,000, and by 1935 the population had grown to 35,500. The population has grown steadily ever since. In 1981 there were approximately 151,000 Navajo Indians, who resided primarily in rural areas on or near the 27,000-square-mile reservation that is located in Arizona, New Mexico, Colorado, and Utah ( ). By 1986, the Navajo population had grown to 171,097, making the Navajo tribe the largest Indian tribe in the continental United States. Today, the Navajo continues to be the largest tribe in the United States, with a population of 362,4888. The Cherokees are the second largest at 273,192 ( ). These new figures represent an increase of 546,891 or 27.1% between 1990 and 2009 for the American Indian population alone (not in conjunction with Alaska Natives) ( ). If the American Indian population was used in conjunction with other races—for example, Alaska Natives—the 2000 Census data suggest that there was an increase in that population by as many as 2.2 million people or 110% ( ).
The 2010 census found that approximately 500 Indian tribes (2,540,309 people) reside in 26 states, with most American Indians residing in the western part of the United States as a consequence of the forced western migration of the tribes ( ). In fact, according to the Bureau of the Census, in 2010, 43% of American Indians reported living in the West, 31% lived in the South, 17% lived in the Midwest, and 9% lived in the Northeast ( ).
According to the 2010 census, the Navajo nation is dominated by those who are under 18 years of age. In fact, the Navajos have a median age of 28.0 years of age as compared with the rest of the general U.S. population at 36.7 years ( ). Women outnumber the men in the Navajo population (51.4% vs. 48.6%). Married-couple families represent only 37.5% of all Navajo families compared with 49.3% of families in the rest of the general population. Similarly, 27.5% of families are female-headed with no father present compared with only 12.5% of the rest of the general population. Of the number of Navajos, 27.9% had less than a high school diploma; 32% had a least a high school diploma; 31.6% had some college education or an associate degree; 6% had a bachelor’s degree, and only 2.6% had a graduate or a professional degree ( ).
It should be noted that there is a clear distinction between American Indians and the Alaska Natives. The term Native American is intended to imply tribes residing in the continental United States (in contrast to Native Canadians). Today, although many American Indians remain on reservations and in rural areas, an equal number reside in cities, especially in Oklahoma, California, New Mexico, and Alaska ( ).
In 2013, the median family income for the American Indians was $27,389, as compared with $62,367 for the U.S. White population ( ). American Indian women fared worse than the rest of the general population, with a median per capita income of $27,570 compared with $35,299, respectively. American Indian men barely made more than White women and made considerably less than the rest of the general population, with a median income of $32,723, compared with $45,320, respectively ( ). The Navajo tribe derives revenue from oil, coal, uranium, and federal grants and contracts. Nevertheless, high unemployment rates continue to be a major problem among the Navajos ( ).
Dialect and Style
The Navajo language is classified as Athapaskan because historically it has been shown to be derived from the languages used by the people of Lake Athabasca in northwestern Canada. The Navajo language is also similar to the languages spoken by some peoples living in Alaska, some on the northern coast of the Pacific Ocean, and some in northern California (such as the Hupas). In addition, Navajo and the 12 groups of Apache dialects form a dialect continuum of one single language. These separate groups speaking a language similar to the Navajo language are referred to as Athapaskans. Among the Navajo, 39.2% speak English only at home; 60.7% speak a language other than English at home; and 15% speak English less than very well ( ).
The language of the Navajo people involves tonal speech in which pitch is of great importance. All vowels and consonants are fully sounded, regardless of how many times they are doubled or tripled in the same word. Vowels are often interchanged, creating several variations and meanings of the same word.
The Navajo language is believed to reflect a concept of the universe that is constantly in motion. In the Navajo language, position is defined as a withdrawal from motion. For example, a person speaking English says “on,” whereas a Navajo person says something directly opposite in meaning for the word “on”: the Navajo speaker says “at rest.” Whereas an English speaker says, “I dressed” or “One dresses,” the Navajo speaker says, “I moved into my clothes” or “One moves into clothes.” The language directly parallels mythological thought in that not only is the language in motion but so too are cultural and spiritual heroes ( ; ).
When Navajo people speak, most of the sentences contain the concept good . For some Navajo people, the concept good may be defined as a favorable or desirable quality that promotes prosperity and happiness. Therefore, the word good is synonymous with other words, such as agreeable, attractive, or beautiful ( nizhóni ). The concept of goodness is directly related to the ideology of health and is even found in the Blessingway healing ceremony. This ceremony is viewed by the Navajos as a “good” event because it promotes everlasting harmony or perfection.
Even today the majority of Navajo people still speak the native language. Although many Navajo Indians are fluent in both the Navajo language and the English language, there are also many who do not speak English and therefore require the assistance of a Navajo interpreter when seeking or receiving health care. The Navajo language does not always have an equivalent single word for an English word; instead, the language uses a description of all occurrences affecting what is being said.
Until recently the Navajo language was unwritten. In World War II, a special branch of the U.S. Marine Corps was developed for Navajos who served as Navajo code talkers. It has been estimated that this highly esteemed group saved millions of lives because the enemy was unable to understand the Navajo language or infiltrate its code.
Instead of shaking hands on meeting another person, as it is practiced in the dominant U.S. culture, Navajos extend a hand and lightly touch the hand of the person they are greeting. Other examples of the use of touch in the Navajo culture include the tradition of massaging a newborn baby as a bonding experience between mother and baby and the tradition of giving a small gift and preparing a small feast for the family when the baby laughs for the first time because this token of esteem touches the heart of all the people around the baby. Another example is the taboo against touching a dead person or an animal killed by lightning, which is extended to touching articles associated with the deceased individual or animal. This taboo is not extended to animals whose death resulted from other natural causes.
Use of Silence and the Importance of Names
On initially meeting strangers, Navajo people may appear silent and reserved. Once the Navajo individual becomes familiar with the other person, warm behavior is usually demonstrated. In addition, when introducing themselves by name, Navajos give honor to ancestors by stating the clan and the location of their home.
Kinesics practiced within the Navajo culture includes the avoidance of eye contact. In dominant cultures in the United States, eye contact is considered important and if not present may cause suspicion. However, the opposite is true in the Navajo culture, where eye contact is considered a sign of disrespect.
In earlier days, Navajo people frowned on pointing anything at another person because pointing was considered insulting. Some Navajos believed that an object being passed to another person should be held upright so that an end would not point at the other person.
In a classic study of language lateralization in Navajo reservation children, one group of Navajo children was tested by a researcher who spoke only Navajo ( ). Another group of Navajo and White children was tested by a researcher who spoke only English. Findings from the study indicate that there appeared to be a strong right-ear advantage for the White children tested by the English-speaking researcher. A similar right-ear advantage was found in the Navajo children when they were tested by the Navajo-speaking researcher, whereas the Navajo children tested by the English-speaking researcher revealed minimal, nonsignificant right-ear advantage. Most of the previous research has suggested that Navajos and other Native Americans have an absence of right-ear advantage. The results of this study were found to be inconsistent with the view that Navajos and other Native Americans are right-brain-hemisphere dominant and thus have a left-ear advantage as a function of the appositional mode of language and thought ( ).
Implications for Nursing Care.
Because the Navajo language does not always have one single word that is similar to one English word in meaning, to do a nursing assessment and develop a nursing diagnosis, goals, and interventions, the nurse must remember that what is being said must be interpreted by approximation. Because some Navajo people do not speak English, it may be necessary to provide a person who is fluent in the Navajo language. When a Navajo interpreter is used, this person must be knowledgeable about medical terminology as well as the cultural aspects of the Navajo lifestyle.
It is also important to remember that the first encounter is not always made to deal with official matters. It is meant to provide an opportunity for the nurse to become acquainted with the family and vice versa. Future rapport with the family is based on this consideration.
Navajo individuals who enter the profession of nursing may experience a cultural shock when care must be provided for a dying patient because of the taboo against touching a dead or dying person and items associated with death. Because of the taboos associated with death, some Navajo nurses may have a healing ceremony performed after contact with a dead person.
Time and space are bound to each other; therefore, it must be remembered that the elimination of time alters spatial concepts ( ). For some Navajo people there is no such thing as imaginary space. Space is so real a concept that it may not be located in any dimension other than real space. For example, space may not be located in the realm of thought; there is no abstract space. For the Navajo Indian, a space such as that found in a room or a house is the same as a small universe ( ).
For the Navajo people, personal living space, or that of the traditional Navajo dwelling ( hooghan , hogan ), is surrounded with many traditions and superstitions or taboos. The hogan is a round, open room with distinct functional areas. Many Navajo people believe that shared space provides a spiritual security and a sense of trust. Sheepskins, with the head facing the fire, are used for sleeping. A wood-burning stove, situated center front with the vent pipe extending through the ceiling, provides a means of cooking food. Taboos associated with death in a hogan include the need to seal the entry, warning other Navajos to stay away, and frequently the need to abandon or burn the hogan when a death has occurred. Another event that renders a hogan unusable is lightning striking in proximity; even wood from such a hogan is never used for any purpose by a Navajo, except for a Navajo medicine man in relation to ceremonies. Before a new hogan is occupied, it is usually blessed by a hired Navajo medicine man, who either strews pollen along the cardinal points or performs a formal ceremony. The hogan is so important to the Navajo culture that all Navajo ceremonies are performed in it. Although the hogan is often crowded with members of both nuclear and extended families, the Navajo need for extension of space is demonstrated by the fact that miles often separate one hogan from another or one camp from another.
Implications for Nursing Care.
Because personal space is so important and has no imaginary boundaries, it is important for the nurse to remember that some Navajo clients may have difficulty adapting to situations that place them in spaces that are not familiar. It is important for the nurse to familiarize the client with the space provided during hospitalization and when personal space is limited during health care administration. The nurse should be sensitive to the fact that a hospital might be unfamiliar to some Navajo people, with new things and experiences, such as different types of foods, different buildings and equipment, different varieties of uniforms, different types of health professionals and support staff, and different types of communication. This situation is particularly true when Navajo clients are hospitalized off the reservation, where Navajo interpreters are unavailable, or when great distances from their home prevent visitation from their extended family.
The nurse may encounter other health concerns and problems related to life in the cramped environment of a hogan, such as infectious diseases from the lack of indoor plumbing and water supply and burns related to the indoor stoves. Lack of food and food storage may contribute to nutritional deficiencies. In addition, the distance between hogans has a public health implication because isolation from the mainstream creates barriers in the delivery of health care. One main barrier is the lack of public transportation. Non–Navajo-speaking public health nurses cope with this barrier with the assistance of Navajo interpreters traveling as a team in a four-wheel-drive vehicle over treacherous terrain and unpaved roads.
The Navajo culture is extremely family oriented, but the term family has a much broader meaning than just referring to the nuclear family of father, mother, and children. The biological family is the center of social organization and includes all members of the extended family. The Navajo people are traditionally a matriarchal society, which means that when a couple marries, the husband makes his home with his wife’s relatives, and his family becomes one of several units that live in a group of adjacent hogans or other types of dwellings.
There is no set numbers or types of relatives limiting the extended family, and their focus is to help one another grow, to collaborate on resources that will provide an adequate livelihood, and to participate in daily life occurrences. Assistance with ceremonies, particularly those associated with birth, death, marriage, or sickness, is shared and has great importance. Usually a male family member who is looked on as having the greatest amount of prestige will rise as leader for the extended family and provide necessary direction. However, in settling issues, all sides are listened to and the entire group determines the outcome.
The family is considered so important in the Navajo culture that to be without relatives is to be really poor; children learn from infancy that the family and the tribe are of paramount importance. In the Navajo culture, being available for a family member is extremely important, and it is common practice for many members of the extended family to come to the hospital and stay with the client or in proximity to the client until discharge. This situation is particularly true of mothers who have a child in the pediatric unit. All efforts should be made to provide overnight accommodations for the mother in the same room with the child if this is not medically contraindicated.
Family Roles and Structure
In the traditional nuclear family, the mother is responsible for the domestic duties associated with the home. The father, on the other hand, is responsible for any outside work necessary to maintain the family and the home. Children are responsible for assisting both parents ( ; ). Within Navajo families, children are viewed as assets, not liabilities. Navajo Indian children are rarely told they cannot do something but instead are frequently told of the consequences of doing a particular thing ( ; ). Children are encouraged by their parents and members of the extended family to live and learn by their decisions. Because the Navajo traditions are passed down by the elderly, Navajo children are taught to respect tradition and to honor wisdom ( ; ).
Despite the role assumed in the family, family support is critical to the Navajos. examined active family nutritional support to determine if there was an association with improved metabolic outcomes for the Diné (Navajo) individuals who had Type 2 diabetes. Findings from this study suggested that active family nutritional support is significantly associated with specific indices for maintenance of diabetes such as control of triglyceride, cholesterol, and hemoglobin A 1c levels. Further findings of this study suggested that the Navajo family in its aggregate is a more useful unit of intervention compared with the individual alone, especially when designing diabetes care interventions.
Some Navajo marriages are still arranged. In any case, marriage and the family are considered the foundation of Navajo life. In Navajo society, women are expected not to excel or achieve more success than their husbands ( ; ). This is even the case among some female Navajo nurses, who may be cautious about excelling in the profession at the risk of their marriages. In earlier times, divorce among traditional Navajos occurred when the wife placed her husband’s belongings outside the hogan ( ; ). conducted a qualitative study among two Navajo Nation chapters to determine factors that made these Navajo marriages strong. The sample consisted of 21 couples who believed they had strong marriages. Factors for strong marriages were identified and included (1) the ability to maintain open lines of communication, (2) taking the opportunity to learn about the importance of marriage, (3) providing time to nurture the relationship, and finally (4) providing the opportunity to build a solid and strong foundation.
Traditional Navajo Dress
The dress of traditional Navajo women has been adapted from the dress of the Spaniards encountered during the internment of the Navajo people at Fort Sumner. The dress usually consists of long, gathered calico skirts and brightly colored velveteen blouses. Because of the harsh terrain and great amount of walking done by Navajo women to get from one place to the other, sneakers and socks are the primary type of footwear.
Traditional Navajo men have adapted the western type of garb, which includes jeans, cotton western shirts, boots, and wide-brimmed hats. Both men and women commonly carry woolen blankets and wear large amounts of turquoise, coral, and silver jewelry as well as ornate buttons and belts. Also, both men and women traditionally wear their long hair tied in a knot behind their head; the knot is covered with rows of white woolen yarn.
Historically the Navajo people have been guided by sacred myths and legends that describe the tribe’s evolution from inception to the present. Supernatural beings portrayed in these stories symbolize the Navajo culture, in which religion and healing practices are blended. Values and beliefs intrinsic to their culture and religion form the Navajo day-to-day living experiences.
Implications for Nursing Care
It is important for the nurse to remember that both the nuclear family and the extended family are of paramount importance to the Navajo client. Because Navajo people believe that family members are responsible for each other, it is not uncommon for many relatives to come to the hospital to care for the Navajo client. Restrictive hospital rules that allow only two visitors at a time or only immediate relatives have no meaning for some Navajo people. The nurse and other members of the health care team should be sensitive to the reality that hogans and camps are at times located a great distance from one another and that visiting a sick relative in the hospital may necessitate travel for many miles, with other family sacrifices needed to obtain funding for this journey. Referral to appropriate available resources will have a positive influence on family-centered care. The presence of family members also provides an ideal opportunity for their inclusion in discharge-planning sessions. Flexibility in scheduling follow-up clinic appointments should also be considered.
Because the Indian kinship or clan system is unfamiliar to most nurses in the United States, it is important for the nurse to develop a sensitivity to and an understanding of the significance of Indian clanships. For example, not only does one inherit lineage from one’s mother, but it is also common for a Navajo child to have several sets of grandparents, uncles, cousins, brothers, and sisters. Among the Navajo people, first cousins may be treated as brothers and sisters, and great aunts and uncles as grandparents. The whole system of clanship may prove to be thoroughly confusing to the nurse because several sets of grandparents, brothers, sisters, uncles, and aunts may show up at the hospital, all claiming close relationship to the client.
The cultural interpretation of time has a temporal focus that views human life as existing in a three-point range that includes past, present, and future ( ). Navajo Indians are viewed as being primarily present-time oriented. However, it should be noted that some Navajo Indians are perceived as being both past- and present-time oriented. The common orientation regarding the man–nature theme is a mixed perception that espouses that man is subjugated to nature and at the same time is suggestive that man should learn to live in harmony with nature. In a classic study by , it was noted that the present-time orientation was the preferred mode of time orientation for the population of Rimrock Navajos sampled. The findings of the study also suggested that past-time orientation was somewhat more preferable than future-time orientation but that the difference in preference was not statistically significant. In the study it was also noted that although some of the respondents preferred to be perceived as being subjugated to nature, the one significant preference was a perception of being in harmony with nature.
Implications for Nursing Care
Most people in the dominant culture in the United States are regulated by clocks and are therefore very time conscious. Future-oriented individuals may have a great deal of difficulty with some Navajo people because of their present-time orientation. It is important for the nurse to remember that because Navajo Indians are perceived as being present-time oriented, time is viewed as being on a continuum, with no beginning and no end ( ). In some Navajo homes there are no clocks because Navajo time is casual, present-time oriented, and relative to present needs that must be accomplished in a present-time frame. Because certain tasks are associated with present needs, it may be difficult for the nurse to counsel and advise a Navajo client about crucial future events, such as taking medications. The present-time orientation of a Navajo client may cause this person to eat two meals today, four meals tomorrow, no meals the next day, and three meals the day after. This becomes an important nursing implication if a client is told to take the medicine with meals, particularly if the medication is to be taken three times a day. Another indication of the Navajo present-time orientation is related to the failure to keep clinical appointments.
Some Navajo Indians are perceived as having an external locus of control; although they believe that man is not subjugated to the effects of nature, they also believe that it is essential for man to live in harmony with nature and its elements. As mentioned earlier, noted that the Rimrock Navajos sampled preferred the orientation theme of “man in harmony with nature.” One conclusion from the study was that some Navajo Indians had a mixed locus of control that was suggestive of both a “being”-oriented and a “doing”-oriented culture.
In the past, self-esteem and a health-oriented locus of control have been postulated as predictors of attitudes and behaviors directly related to children’s health. A classic study by was done to measure the relationship between self-esteem, a health-oriented locus of control, and health attitudes of Navajo children in the fourth to sixth grades. The analysis of the data indicates that there is a statistically significant relationship between self-esteem and positive attitudes toward health. In addition, the study found that self-esteem was a modest predictor of health attitudes and health behavior intentions among Navajo and Pueblo children.
A craniofacial team at the University of New Mexico Medical Center at Albuquerque were successful in the treatment of a large population of Navajos because of team awareness of the Navajo concept of health ( ). This understanding of the Navajo concept of health, in which man is viewed as being in balance with the environment (and therefore an understanding of the Navajo concerns with ghosts, “skinwalkers,” and rules for orderly living), allowed team members to integrate the family, as well as the Navajo medicine man, into the care and treatment of children with craniofacial diseases. In addition, to provide culturally appropriate care, the craniofacial team had to develop an understanding of traditional Navajo healing ceremonies and the need for special handling of disposed body parts during surgery.
Illness and Wellness Behaviors
Traditional Navajo concepts espouse the need for the Navajo people to be in harmony with the surrounding environment and with the family. Some Navajo Indians have a perception of health that is not limited to the physical body but encompasses congruency with the family, environment, livestock, supernatural forces, and community. To maintain spiritual health, some Navajo people believe that it is essential to be in harmony with supernatural forces. concluded that health and religion cannot be separated in the Navajo world; rather, the link between traditional religion and healing ceremonies found among Navajo Indians is obvious.
Traditional Navajo concepts of health and disease have a fundamental place in the Navajo concept of man and his place in the universe. Native healing ceremonies encompass traditional Navajo medicine and general native healing practices and form the foundation of Navajo culture. These ceremonies are central to the attitudes, beliefs, values, and perceptions of the Navajo people.
Blessingway is the main philosophy from which more than 35 major and minor ceremonial variations are derived. This Navajo practice attempts to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings ( ; ). In the Blessingway ceremony, the importance of family and clan members is emphasized in the healing process. The mother is considered particularly important because she can relate prenatal incidents of ill nature that affect health.
Navajo medicine men and medicine women spend many years learning their skills and serving as apprentices. There are several types of medicine men and women:
Diagnosticians are those who diagnose illness or the cause of disharmony. Their title may be “crystal gazer” or “hand trembler,” depending on the method used in diagnosing the patient.
Singers ( hataaii, an undifferentiated singular-plural noun) are those who perform and direct the elaborate and complex healing ceremonies.
Herbalists are those specialized practitioners who use herbs to treat patients and who may also diagnose illness and causes of ailments.
Medicine men and medicine women have jish, or medicine bundles, containing symbolic and sacred items, including corn pollen, feathers, stones, arrowheads, and other instruments used for healing and blessing. Many of these sacred objects and plants are found on the sacred mountains that border the Navajo reservation and are gathered only by medicine people ( ; ).
There is great effort on the part of the Indian Health Service and the traditional Navajo healers to work together in a collaborative and cooperative way. It is not uncommon to observe a medicine man or medicine woman in the hospital speaking with a physician regarding the care of a client. When medically indicated, clients may also receive passes to participate in a healing ceremony held outside the hospital. There has been a continued and sustained mutual respect on the part of these two groups for the expertise of the other ( ).
In 1984, in a classic study, the Navajo Health Systems Agency conducted a research study to investigate the types of traditional healing services being provided and the types of cultural orientations to traditional healing practices being provided for newly hired Indian Health Service care providers. The conclusions of the survey reiterated the need for continued and improved collaboration and cooperation between traditional medicine people and Western physicians. For example, serious cases of injury and illness are often referred to the hospital by medicine people, and physicians have sent clients to medicine people when deemed appropriate, particularly in cases of psychological or behavioral disorders ( ).
Death and Dying Rituals
The Navajos are considered a traditional people. They have often been characterized as being very respectful of death and the dead ( ; ; ). Yet it is essential to remember that the beliefs held by the Navajos depend on personal experience; the level of acculturation into traditional U.S. society; and beliefs in traditional religion, Christianity, and/or in the Native American Church. Traditional Navajos are so respectful of the dead that they do not touch the body ( ). In fact, when a Navajos dies, it is suggested by tradition that other Navajos not touch the body ( ). It is thought that if a Navajos touches the body of the dead, the spirit of the deceased might contaminate that person and thus the individual would require what is known as a “cleansing ceremony” ( ). Some Navajos believe that the ghost of the dead might possibly return to his or her home, so traditional Navajos may build a temporary home or hogan away from the main home and move the dying person to this new structure ( ). It is essential to remember that even traditional Navajos may send terminally ill Navajos to the hospital. The dead are usually quickly buried by the Navajos ( ). The Navajos tend to avoid discussion of death and dying as it is a revered experience, and the name of the dead is not spoken out loud ( ). The afterlife for most Navajos is not necessarily equated with reward, good behavior, or a quality of one’s life ( ). Some researchers contend that while the Navajos believe in the afterlife, it is perceived as only a very “shadowy and uninviting phenomenon” ( ; ). For Navajos who commit suicide, such an individual is believed to be destined to carry the object used to commit the suicide in the afterlife ( ). The Navajos have been slow to embrace the concepts of advance directives or truth in disclosure of terminal illness. For example, found that because the Navajos believe that thought and language shape reality, discussions of negative information such as the disclosure of risk in informed consent, truth in telling about terminal illness, and advance directives for future illness may all possibly be a violation of traditional Navajo values.
Implications for Nursing Care
To a Navajo Indian, being is a fundamental concept; as mentioned earlier, Navajos are considered more “being” oriented than achievement oriented. Individuals are perceived as being more important than possessions, wealth, or other material things. If something is perceived as good, it is only as good as its value to other people. It is important, therefore, for the nurse to remember that some Navajo Indians believe that goodness is found only when one is in complete harmony with the surrounding environment. The nurse should also keep in mind that if a Navajo is to have the perception of being in harmony with the environment, the environment must be structured in such a way that harmony is promoted. If a nurse were to deny or not allow the client the opportunity to achieve harmony with other people, animals, plants, nature, weather, and supernatural forces, the client would not be able to obtain a sense of assuredness in relation to physical, social, psychological, and spiritual health.
It is important for the nurse to determine which cultural health practices are beneficial, neutral, or harmful to the client to provide culturally appropriate care. If a cultural practice is considered either beneficial or neutral, the practice should be incorporated into the plan of care. However, if a cultural practice is considered harmful, the nurse should devise a teaching strategy that will assist the client in developing an understanding of the implications of the practice on continued health maintenance. For example, after delivery the umbilical cord is taken from the newborn, dried, and buried near an object or place that symbolizes what the parents want for the child’s future. Burial close to the home of the infant signifies the continued tie or relationship with the child’s home and Mother Earth. Because this neutral practice does not negatively affect health care, it should be acknowledged, accepted, and incorporated into the plan of care. Also, to provide culturally appropriate nursing care, it is essential that the nurse respect the need for Navajo people to maintain traditional rituals even when hospitalized. For example, it would not be uncommon for a Navajo individual to sprinkle certain foods, such as corn and cornmeal, around the bedside during a curative ritualistic ceremony. The nurse who comes in the room and finds cornmeal around the bedside may initially be disturbed and insist that it be removed. However, the nurse should keep in mind that this cornmeal (as well as other rituals) is extremely important in the ritual and that, because it does not have any negative health-related implications, it should be left at the bedside until the client and the family desire its removal ( ).
The U.S. government has passed numerous acts and implemented numerous programs specifically to address health-related issues among the Navajo people and their involvement in the determination of their health care. The 1975 Indian Self-Determination Act provides that any federal program serving the health needs of Navajo people may be either self-determined or contracted for by the Navajo tribe or its designee. Services contracted for must be comparable to or exceed existing services under the direction of federally operated programs, such as the Indian Health Service. Through collaborative efforts, the commitment to improve the health status of the Navajo population and to increase tribal involvement in health care management has been enhanced, reconfirmed, and extended to other components of health care ( ).
The basic authority for health care for American Indians and Alaskans is provided by the Snyder Act of 1921. The Bureau of Indian Affairs assumed responsibility as a federal branch for providing health care services for the Navajo people until 1954. At that time, the responsibility was transferred to the Indian Health Service as a result of the U.S. Transfer Act of 1954. In 1967 the Navajo area of the Indian Health Service was established to address the health care needs of Navajos. Today, the Navajo area is one of 12 areas within the Indian Health Service and has its administrative location in Window Rock, Arizona.