Note: This article was originally published by the American Indian Cancer Foundation for Colon Cancer Month. When the emcee called for cancer survivors to come out to the floor at the 2013 Powwow for Hope, Robert DesJarlait (Red Lake Band of Chippewa) walked out to the shock of all those around him. “It was an emotional experience” Robert said, reflecting on his decision to go public for the first time about his cancer story. Although he hadn’t officially been diagnosed at the time of the powwow, he knew deep down that it was true. Today, Robert feels it is his responsibility to share his cancer story. When Robert started to notice symptoms of colon cancer in 2013, he became afraid because he knew cancer ran in his family. His father died of stomach cancer in 1972. After getting sick and going to the hospital, he found out his red blood cell count was low, so his specialist ordered a colon test and a biopsy. Robert had surgery to remove his ascending colon and lymph nodes, which confirmed that he had cancer, but brought the good news that it had not broken through the colon wall. Robert’s follow-up care included a yearly CAT scan and colon test, and it was three years later that they found a precancerous polyp. A few months after the polyp was removed, a tumor was found in the left lobe of his liver and his neck. The tumor in his neck was not dangerous, but the one in his liver had to be removed. He went through chemotherapy and then surgery in 2016 which left him on the table for nine hours. In January of 2017, Robert started chemo again to remove any traces of cancer that might be left. He has lost all his hair with “no stubble left” and the main thing he struggles with is the fatigue. “Since I’m an active person, it’s hard to deal with.” Robert uses traditional medicine during his treatment to achieve balance between his physical, mental and spiritual healing. His approach to healing comes from traditions that he has learned throughout his life and include bringing his eagle fan to treatment, offering tobacco and smudging. He believes in the power of traditional medicines to carry him through his cancer journey: “When we get cancer, we have doctors that can remove it, but we have ways of bringing a balance in how we deal with it personally. I don’t believe we have medicine that cures cancer, but we can take care of it in a traditional way. It’s been an important part of healing, combining the two together. If you approach it spiritually, the emotional and physical aspects are brought into balance.” Robert has been vocal about his cancer journey since 2013. While he understands that some people may be uncomfortable talking about cancer in American Indian communities, he has made the decision to face it head on. When Robert used to look at his cancer scar in the mirror, he would ask himself “Why me?” With reflection, he discovered that the Creator’s role for him was to be a cancer educator and he embraces it. “Creator put me in this role in the community to speak out about it. Creator wants me to talk about it.” Robert talks about his cancer story to encourage people to get screened. “If I had gotten my screening when I was supposed to, I probably would never have gotten cancer.” Screening is recommended to start at 45 years of age for American Indians due to their high risk of the disease. “It’s interesting that there are more and more people with cancer. It floors me with what is going on here. If everyone got tested and screened regularly, we wouldn’t see these people cancer.” He warns: “It’s important to get your screening – otherwise you could end up like me.”
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One of my experiences on my cancer journey has been sharing my cultural teachings and traditions, in regard to health and healing, with doctors and nurses who are grounded in Western concepts of healthcare. Passing on such knowledge is limited to the time constraints of doctors and nurses in their hectic, busy schedules, so I’m not able to provide anything that is in-depth. But given the opportunity, I try to do the best I can. The most recent example is the surgery I had for recurrence of cancer on November 10, 2016. The recurrence was the result of colon cancer metastasis to the left lob of my liver. I brought my eagle fan with me. It hung from my IV stand during my four-day hospital stay. As such, it became an object of curiosity to the doctors and nurses who came to my room. When asked about it, I said my eagle fan has a history to it, and that it is something I carry as a traditional dancer. But it has been used for ceremonies and healing. The fan has a spirit within it, and it is a spirit that protects, heals, and carries my thoughts and prayers to the Creator. I also explained the four aspects of the medicine wheel – emotional, mental, physical, and spiritual – with the objective of maintaining a balance for a healthy well-being. But because the time was limited, I mainly focused on the physical and spiritual aspects. I explained that my surgery and the healthcare I was receiving in the hospital represented the physical aspect, and my eagle fan represented the spiritual aspect. My dialogue with these health care professionals may, at first, seem to be curiosity on the part of my cancer team. But at a deeper level, cultural safety and cultural competency were, I believe, at play. Volumes have been written about cultural safety and cultural competence in healthcare. And there are various interpretations as to the meaning of cultural safety. On one level, cultural safety may mean creating a safe environment for patients regardless of race, ethnicity, and background. But on another level, cultural safety has a specific meaning in regard to the mutual interaction between health care professionals and Indigenous patients. The basis for cultural safety has its beginnings in New Zealand in 1989 in regard to Maori nurses and patients. In 2009, Canada adopted cultural safety in regard to First Nations, Inuit, and Métis peoples. In the U.S., cultural safety has been problematic. In a 2012 study, it was noted that “[a]s nurse educators, the U.S. authors of this article experienced discomfort with the cognitive approach for cultural education focusing on the ‘values, beliefs, and traditions of a particular group’ and tending to view culture as ‘static and unchanging.’”[1] Further, “[t]hough health researchers and practitioners in the United States frequently use similar sounding terms (e.g., cultural awareness, cultural sensitivity, and cultural competence), these terms lack cultural safety’s political commitment to equity in health care research and delivery, which…is necessary to address health inequities between Indigenous and non-Indigenous peoples.”[2] Cultural Safety To provide an understanding of the concept of cultural safety, I’ve provided excerpts from several key sources. The full documents are too lengthy to present here. Excerpts are in italics to distinguish from my own comments. Cultural safety in New Zealand: The concept of kawa whakaruruhau (cultural safety) arose out of a nursing education leadership held in Christchurch in 1989 in response to recruitment and retention issues of Maori nurses. In 1990, the Council amended its standards to incorporate cultural safety into its curriculum assessment processes. The cultural safety guidelines were initially written by Irihapeti Ramsden in 1991, and approved by the Council in 1992. They were further developed by a Council committee (1996), led by Irihapeti Ramsden, in response to the recommendations arising from the Cultural Safety Review Committee (1995). 1. Cultural Safety Cultural safety relates to the experience of the recipient of nursing service and extends beyond cultural awareness and cultural sensitivity. It provides consumers of nursing services with the power to comment on practices and contribute to the achievement of positive health outcomes and experiences. It also enables them to participate in changing any negatively perceived or experienced service. The Council’s definition of cultural safety is: The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability. The nurse delivering the nursing service will have undertaken a process of reflection on his or her own cultural identity and will recognise the impact that his or her personal culture has on his or her professional practice. Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and well being of an individual. Principles of Maori Health and Nursing Practice: Nursing has a responsibility to respond to Maori health issues by improving the delivery of nursing services to Maori to ensure that they are responsive to, and acknowledge and respect the diversity of world views that may exist between Maori consumers of health services. This will be underpinned by nurses having an analysis and understanding of the historical processes and social, economic and political power relationships that have contributed to the status of Maori health, the Treaty of Waitangi and of kawawhakaruruhau (cultural safety) within the context of nursing practice. (Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice, Nursing Council of New Zealand, First published March 2005, Last amended July 2011) Cultural safety in Canada: Terminology: We use the term Indigenous to refer to “communities, peoples and nations…which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or part of them. They form, at present, non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as a basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal system.” In Canada, the Constitution terms Indigenous peoples as Aboriginal and includes First Nations, Métis and Inuit peoples. Health disparities between First Nations, Inuit and Métis (FN/I/M) peoples and the general Canadian population continue to exist. Canada’s history of colonization of FN/I/M peoples with its resulting racism, discrimination and marginalization continues to affect the health and well being of many communities. Rationale As the First Peoples of Canada, these communities are diverse in their languages, beliefs, histories and health practices. And while varied languages, histories and health practices may also be true of cultural groups who have immigrated to Canada, FN/I/M peoples are not a cultural group to Canada, but rather distinct constitutionally recognized peoples with Aboriginal and treaty rights. (First Nations, Inuit, Métis Health: Core Competencies, A Curriculum Framework for Continuing Medical Education, The IPAC-RCPSC Advisory Committee, March 2009) … All registered nurses, who graduate from nursing programs in Canada, should understand the unique relationships between the First Nations, Inuit, and Métis and the Government of Canada. It is imperative that graduates from nursing programs comprehend the historical and contemporary contexts of Aboriginal peoples; Best-practice nursing curricula should prepare Aboriginal and non-Aboriginal graduates who are competent to work with the First Nations, Inuit, and Métis peoples. Furthermore, such curricula should privilege and respect indigenous knowledge and expose students to these epistemological and ontological foundations, and; There is a need to contemporize the concept of “culture” as it is understood and taught within undergraduate nursing programs. Within the education and practice domains, culture is most often understood and practiced in its essentialist form. Culture, from a constructivist perspective, fosters awareness, sensitivity, competence, and moreover the need for cultural safety in the care of clients, including the First Nations, Inuit, and Métis peoples. Cultural Safety Cultural safety takes us beyond cultural awareness and the acknowledgment of difference. It surpasses cultural sensitivity, which recognizes the importance of respecting difference. Cultural safety helps us to understand the limitations of cultural competence. Cultural safety is predicted on understanding power differentials inherent in health delivery and redressing these inequities through educational process. Addressing inequities, through the lens of cultural safety, enables care providers, including nurses, to:
1. Postcolonial understanding: Postcolonial theory accounts for health disparities and health inequities among First Nations, Inuit, and Métis. It is the examination of colonialization and its affect on the lives of Aboriginal peoples, and includes examining the relationship between residential schools and historic trauma transmission. 2. Communication: This concept entails effective and culturally safe communication among students and faculty within the teaching/learning contexts; it also applies to nursing interactions with the First Nations, Inuit, and Métis peoples. 3. Inclusivity: This concepts invokes action where increased awareness and insights are required as part of the engagement process and relationship building with the First Nations, Inuit, and Métis peoples. 4. Respect: Respect for First Nation, Inuit, and Métis cultural integrity is one of the guiding principles originating from the perspectives of Aboriginal communities. Respect is the show of consideration for First Nation, Inuit, and Métis students, their families, and communities for who they are, their uniqueness, and diversity. This concept entails effective communication and collaboration with both Aboriginal and non-Aboriginal health care professionals, traditional / medicine peoples / healers in providing effective health care for First Nation, Inuit, and Métis clients, families, and communities. It also includes working with First Nation, Inuit, and Métis groups and communities when conducting research to improve the health of the Aboriginal population. 5. Indigenous knowledge: This concept is the acknowledgement of traditional knowledge, oral knowledge, and Indigenous knowledge as having a place in higher learning along with literate knowledge. It also includes First Nations, Inuit, and Métis ontology, epistemology, and explanatory models related to health and healing; and First Nations, Inuit, and Métis cosmologies(spirituality, range of religious beliefs, etc.) (Cultural Competence and Cultural Safety in Nursing Education: A Framework for First Nations, Inuit, and Métis Nursing, Aboriginal Nurses Association of Canada, 2009) Cultural Competency Cultural safety hasn’t been formally adopted into health care systems in the U.S. Instead, the focus is on cultural competency. However, cultural competency isn’t mandated. Rather, there are guidelines for healthcare providers to follow. The purpose of this document is to initiate a discussion of a set of universally applicable standards of practice for culturally competent care that nurses around the globe may use to guide clinical practice, research, education, and administration. The recipient of the nursing care described in these standards is assumed to be an individual, a family, a community, or a population. These standards are based on a framework of social justice, that is, the belief that every individual and group is entitled to fair and equal rights and participation in social, educational, economic, and, specifically in this context, health care opportunities. Culturally competent care is informed by the principles of social justice and human rights regardless of social context. Through the application of the principles of social justice and the provision of culturally competent care, inequalities in health outcomes may be reduced. The worldwide shortage of nurses and the global migration of both nurses and populations have heightened the need to educate nurses to deliver culturally competent care for an increasingly diverse patient population, regardless of geographic location. This need served as the primary impetus for this work. Cultural standards exist within political, economic, and social systems. Many health organizations throughout the world have defined care for their specific populations from the perspective of these systems. The variation among standards and the context within which standards are practiced precludes a single set that fits all cultures. Culturally Competent Nursing Care: Standard 3: Knowledge of Cultures Nurses shall gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations for whom they care, as well as a knowledge of the complex variables that affect the achievement of health and well being. Cultural competence is a dynamic, lifelong learning process. Understanding the process for assessing cultural patterns and factors that influence individual and group differences is critical in preventing overgeneralization and stereotyping. Knowledge of the following topics is essential to provide evidence-based, culturally competent nursing care: • The impact of culture on attitudes, values, traditions, and behavior • Health-seeking behaviors of individuals, families, communities, and populations • The impact of language and communication styles of individuals, families, and communities • The impact of health policy on culturally diverse groups, particularly targeting those who are economically disadvantaged, vulnerable, and underserved • Resources (personal/familial social support networks, professional human resources, agencies, and research) that can be used by culturally diverse individuals, families, and communities. Professional nurses need specific knowledge about the major groups of culturally diverse individuals, families, and communities they serve, including, but not limited to: specific cultural practices regarding health, definitions of, and beliefs about, health and illness; biological variations, crosscultural worldviews; acculturation, and life experiences, such as refugee and immigration status, as well as a history of oppression, violence, and trauma suffered. Culturally competent assessment skills are essential to facilitate communication, to demonstrate respect for cultural diversity, and to ask culturally sensitive questions about beliefs and practices that need to be considered in the delivery of health care. The more knowledge a nurse has about a specific culture, the more accurate and complete the cultural assessment will be. For example, if nurses are not aware that many Hispanics use traditional healers such as curandros, masjistas, sobodoes, y(j)erberos, and esperititas, they will not know how to ask specific and appropriate questions about the individual’s use of these alternative practitioners and their therapies. Because nurses cannot know the attributes of all cultures, it is essential to use a cultural assessment model or framework. Thus nurses should seek specialized knowledge from the body of literature in transcultural nursing practice, which focuses on specific and universal attitudes, knowledge, and skills used to assess, plan, implement, and evaluate culturally competent nursing care. In addition, nurses need knowledge of the types of institutional, class, cultural, and language barriers that may prevent culturally diverse individuals and families from accessing health care. Knowledge can also be gained from associated disciplines such as anthropology and sociology. Standard 4: Culturally Competent Practice Nurses shall use cross-cultural knowledge and culturally sensitive skills in implementing culturally congruent nursing care. Cross-cultural practice in nursing involves a complex combination of knowledge of diverse cultural practices and worldviews, reflective self-awareness of own cultural worldview, attitudes about cultural differences, and skills in cross-cultural assessment and communications. Cross-cultural practice begins with a thorough assessment of the physical, psychological, and cultural foci as the basis of the planning of care. The cultural focus of assessment entails examining the sociocultural, ethical, and sociopolitical features that are uniquely situated within the health–illness continuum of diverse clients. Inherent in effective assessment is cross cultural communication skills, used to maximize common understanding and shared meaning of the health–illness encounter of the culturally diverse client. Competence in cross cultural practice is a process requiring experience and continued interest in learning and in sharpening cultural assessment and communication skills. Although nurses may achieve a certain degree of competence in some diverse cultures, they cannot be totally competent in all cultures (Eubanks et al., 2010). Yet nurses are more likely to achieve culturally competent cross cultural care when the complex combination of cultural knowledge, awareness, attitudes, and skills are used dynamically for cultural assessment of clients’ health beliefs and practices, and for negotiating culturally congruent health interventions through skillful cross cultural communication. Implementation of this standard will be influenced by the level of nurses’ knowledge of client’s cultural health beliefs and practices, by their intentional reflection on their own attitudes, by their skill in cross-cultural communication, and by their ability to assess and implement culturally congruent care. To ensure adequate preparation of nursing students, these variables must be fully integrated throughout the nursing curriculum. To enhance nurses’ competency in cross-cultural practice, clinical institutions and health care facilities need to provide ongoing educational workshops as well as mentoring and training geared toward the continuous development of nurses’ cultural knowledge and skills for effective cross-cultural practice. (Journal of Transcultural Nursing, Standards of Practice for Culturally Competent Nursing Care: 2011 Update, Marilyn K. Douglas, Joan Uhl Pierce, Marlene Rosenkoetter, Dula Pacquiao, Lynn Clark Callister, Marianne Hattar-Pollara, Jana Lauderdale, Jeri Milstead, Deena Nardi and Larry Purnell) Cultural Safety in the United States One reason why U.S. health care organizations have not adopted the concept of cultural safety as readily as Canada may be rooted in historical and political factors. The experience of colonization in the United States is somewhat different from in Canada. Canada is a Commonwealth country, whereas the United States is an independent nation. Therefore, Canadian residents’ experiences of being governed from afar and their clear and ongoing connection to an imperial power (the United Kingdom) continue to this day. Because cultural safety is discussed and rooted in terms of colonialism, academics and scholars in the United States may not relate to cultural safety, or may not as readily identify the need for a process of decolonization in health care. Challenging existing power structures through the practice of cultural safety can result in both social and political consequences that organizations may not be willing or prepared to confront. Indeed, the call to decolonize existing health care systems is politically charged in that they are predicated on the acknowledgment that existing systems are failing specific populations. Second, we suggest that tenets of cultural safety may actually be adopted within the U.S. context, but the language used in articulating it may not engage with the term. For example, some organizations that state that they are engaged in the promotion of cultural competence may in fact be engaged in supporting culturally safe approaches to health care and research. (Journal of Transcultural Nursing,The United States Does CAIR About Cultural Safety: Examining Cultural Safety Within Indigenous Health Contexts in Canada and the United States, Francine Darroch, PhD, Audrey Giles, PhD, Priscilla Sanderson, PhD, Lauren Brooks-Cleator, MA, Anna Schwartz, PhD, FNP-BC, FAAN, Darold Joseph, MEd2, and Roger Nosker, BS, 2016) To put the concepts of cultural safety and cultural competency into a personal perspective, I’ll relate two experiences (of many) that I’ve had with nurses. In 2012, I had a heart attack that resulted in an emergency angioplasty. There was a nurse who asked me about the things I had on my hospital bed. On my bed, next to me, I had my eagle feather fan, my eagle whistle, and a pouch of asemaa (tobacco). Around my neck I wore a medicine bag. I told the nurse that when I was first admitted to the hospital, I was asked what my religion was. And I had responded to the person interviewing me that my fan, my whistle, my asemaa were my religion or, more specifically, my spirituality. I told the nurse that what helped me was Indigenous medicine. Western medicine healed my heart physically and traditional medicine healed my heart spiritually. The nurse, who was originally from Nigeria, understood what I was saying. She said: “Where I’m from, our medicine is water. Our water protects us. Part of life is about medicine and it is important to believe in the medicine because only then does the medicine heal.” My other experience was my recent cancer surgery in November 2016. A Vietnamese nurse came to check my vitals. She noticed the medicine bag I was wearing and asked about it. I told her the bag had Western medicine in it, i.e., my bottle of nitro pills, and the four traditional medicines – cedar, sage, sweetgrass, and tobacco. And it also had a stone given to me from a Lakota friend. She said that her people also had personal medicine bags. She said her medicine bag was made from red fabric and kept on the wall of her house for protection. These are but two examples that I’ve encountered with health care professionals. Although these are not examples of cultural safety, they do display the tenets of that concept. Cultural safety is a reciprocal relationship between a health professional and patient in which there is an exchange of mutual respect between culturally diverse individuals. And in that exchange, one learns something about the other’s culture. Traditional Healing In the foregoing excerpts regarding cultural safety/competency, the role of the traditional healer is recognized. The following excerpts more specific examples of traditional healers actively involved in hospital and clinical settings in Canada and the U.S. Traditional Healing in Canadian Hospitals: In the study I wish to discover if indigenous healing practices are able to adapt to a setting that is so central to the definition of settler states. I do so within a broader perspective that sets healing within a study of the decolonization process. The main argument is that part of the road to healing lies through the official institutions of the Canadian medical system and that it involves decolonization process for both the indigenous and the dominant society. The thesis asks why are hospitals settings being chosen today as the places to establish indigenous healing services and practices? To answer this question the thesis employs qualitative interview data and a reading of the literature. One of the key answers is that the hospital context permits the community of biomedical practitioners and the indigenous healers to interact. On the one hand, this interaction is seen as an important step for the revalorization and formal recognition of indigenous knowledge, and as determinant for the preservation and survival of it. On the other hand the field research shows that aboriginal patients feel extremely vulnerable when hospitalized and that the integration of indigenous healing within hospitals would improve the quality health care. I also encountered difficulties with the type of language that my informants used. For example many used specific Cree terms or used English terms that held a nonstandard meaning. For example, terms such as ‘Elders,’ or ‘grandfathers’, are English words which do not correspond to the Standard English meaning. The term ‘grandfather’ is used with a different meaning depending on the context. During the interviews it was generally used as the Spirits who act as a wise guide through the journey of life and in some cases provide the sacred knowledge of healing. The same is true of the key term ‘Elder’. In Standard English this term refers exclusively to age, but in the usage of Plains Cree and other Canadian aboriginal people it refers to a ‘wise person’ who is usually elderly. Not every old person is an Elder, nor every Elder has to be old in order to be an Elder. However Elders are normally over 50 years old, since is understood that a person needs a long journey before to reach enough experience and therefore wisdom to share. The terms healing and medicine are used interchangeably by my informants. As I explained in the beginning of this chapter, in some cases they referred to healing as a philosophy and style of life, as a broad way of approaching the people’s well-being. In other cases, though, they talk about healing as a more specific type of medical knowledge, the art and the gift of healing or doctoring. In this sense healing knowledge is in the hands of a few persons. These people are generally called healers. The medical skills that they have are related to the gift of helping people to become well and it (healing) involves a spiritual gift but also a learning process based on traditional medical skills. The fact that healing is both given and acquired is an important point that is often overlooked. The Plains First Nations worldview believes that one learns doctoring. Healing however happens because of the spirits of the herbs, and the spiritual gift given to the healer. Cree people believe that the gift of healing is given already in the womb before the healer is born. Teachings begin at an early age for those chosen for the learning of natwapokahn [the all-purpose medicine] (Cardinal, personal interview). For example, today, some people learn how to do healing ceremonies and become popular; however, the spirit and the moral bases for the power of a healer in order to heal cannot be learnt. Without the spiritual gift they are not considered healers from their own people. Therefore the “keepers of traditional healing knowledge have more than knowledge. They are well-known within the communities and exemplify an unusual capacity for humility. The main contrast between the two types of medicine is related to the following differences: • The practitioners of bio-medicine (except public health) focus on the individual not in the community • Bio-medicine is based in positivist research not in sacred or spiritual thinking • Bio-medicine focuses on the recovery or restoration of biophysical aspects of the person and does not consider the identity of the individual. Its goal is to treat illness not the whole wellness of the person. The historical basis of relationships between indigenous people and the colonizers, and the well-settled assumptions of inferiority-superiority asserted to aboriginal and mainstream communities, respectively, are difficult to heal. These distinguish the situation that indigenous people suffer from other minority groups like immigrants. However, the problems related to different cultural ways of seeing the world and the needs and values that derive from this can easily be fixed. Of course, training and aquisition of cultural competence by the hospital staff is very relevant, but the implementation of aboriginal programs and other services that make the experience of aboriginal patients more satisfactory is key as well. The community Elders started to think that the best person to fit this job was the oskapewis or “traditional helper”. The role of oskapewis in Cree communities involves “honouring the Creator, learning through service and experience about ceremonies, giving humble and respectful service for others, offering support for people of the community in times of difficulty and preparing ceremonies for Traditional Elders." In relation to the position at the hospital, the Elders thought that the name of this new position should be “Helper”, as this person helps those who suffer within the hospital. The oskapewis should be the right person since this person is able to understand the sacred aspects of some traditions and practices, and to prepare ceremonies under the right protocols and within the right spirit. Besides these cultural abilities, this person should be good at building bridges between native patients and hospital staff. The role played by the oskapewis within Cree communities is supported in the spiritual value to humility, service and trust in the Creator. Cree Elders define the spiritual basis of this role with a say: oskapewis is “about serving the Creator, serving the people and least of all ourselves." These strong values to be humble and to focus on the needs of the people were identified as necessary and basic in order to carry on the responsibilities, challenges and right spirit that the new holder of this position could need. They would help the Helper to be patient and keep going through difficulties. Today, the position of cultural helper is well-established in the main hospitals of the province of Alberta. Through this position, the cultural helper serves hospital staff to better understand their patients, and any aboriginal people who need help. This includes First Nations, Métis and Inuit. An official cultural helper education program has also been established in order to avoid the risk of this role ending up as a temporary experiment and to provide the understanding and skills needed to develop this position. The cultural helper education program now obtains most of its funding from the central budget of the Royal Alexandra Hospital. At the moment, Edmonton is the only place in Canada where this program exists. The main objectives of this program are related to the primary tasks and roles that the position requires. The report about the aboriginal cultural helper education program, submitted from the spiritual and pastoral care services of the Royal Alexandra Hospital, describe main 11 objectives:
The main question to answer has been: Why indigenous healing should be integrated into western bio-medical settings? Others settings have also been chosen for the practice of indigenous healing. Within prisons, or independent health care centres run by First Nations, people are cured of their mental health problems, recover from addictions or domestic violence. (First Nations Healing in the Hospital: On the quest to implement indigenous healing in a clinical setting, Beatriz Zarcos Jimenez, Thesis submitted for the degree: Master of Philosophy in Indigenous Studies Faculty of Humanities, Social Sciences and Education, University of Tromsø, 2012) Traditional Healing in Canadian Clinical Settings: Consensus emerged also on important Anishinabe concepts that were thought to be essential to preserve in the clinical setting. These were incorporated into the traditional healing protocols for the centre (Noojmowin Teg Health Centre, 2007). Anishinabe values are often anchored in words and expressions whose meaning may be lost in translation. For example, in clinical settings a person seeking health services is thought of as a client (a consumer) or a patient (a passive receiver). This is at odds with Anishinabe values of healing, where the person is thought of as an equal partner who is engaging in a healing relationship and is therefore referred to as a relative. To reinforce this concept, the term “relative” is used to refer to people who receive traditional healing services at Noojmowin Teg. Other Anishinabe concepts were identified as vital during the consultations, and were also incorporated into the policies. They include the Anishinabe concepts of bgidniged, debweyendaa and michidoumowin. Bgidniged is the Anishinabe concept of a gift that should be given to a healer by the relative or their advocate. Clients are encouraged to take responsibility for their healing by providing a practical gift to the healer based on their means. The traditional coordinator also arranges for a monetary gift to the healer to cover travel and accommodation expenses. There is an important conceptual difference between payment and the gift or bgidniged. In the Anishinabe understanding, it is impossible to put a price on traditional healing services. The traditional healer is not paid on a fee for service arrangement, but rather provided with a bgidniged reflecting the number of days that they are working with clients at the health centre. The bgidniged from the health centre is in monetary form for practical reasons. While in the past Anishinabe healers may have been gifted with food, hide, horses, or other utilitarian implements to support themselves, today it is difficult to get by without the use of money. The relative however is encouraged to provide the healer with a practical gift. Debweyendaa is the Anishinabe concept of the sacred trust between people and the Creator. It is invoked to convey the expectation of ethical conduct by the healer, creating an appropriate healing relationship with the relative and maintaining confidentiality of services. Michidoumowin is the Anishinabe concept for the breech of debweyendaa, the sacred trust. It is seen as a grave transgression. Michidoumowin is used to convey violations of ethical conduct of traditional healers while providing traditional health services. At the health centre, such a breech would lead to termination of the services provided by the healer. These important Anishinabe traditional concepts of the provision of a gift to a healer, the ethical integrity and sacred trust between healer and client, and a course of action in the event of a breaking of the sacred trust, are outlined in the traditional healing policies and have important implications for integrated practice. These Anishinabe concepts address issues that are also essential for the provision of western medical services, such as patient safety and confidentiality, and provider accountability for misconduct. Incorporating these concepts into the traditional policies has therefore also fulfilled the administrative need for risk management and provides the foundation for collaboration with clinical providers. Health record keeping is a clinical practice that was also seen as important for the traditional services. Record keeping facilitates interdisciplinary practice and long-term follow up care for clients, as well as monitoring of herbal medicines and potential drug interactions. There was consensus that the traditional healers should not be charged with the task of recording in health records. The established protocol therefore includes the provision of an assistant for the healer to record relevant information, such as the traditional diagnosis and the prescribed treatment for the relative, a role filled by the traditional coordinator, a trained helper or another community health worker. This practice also ensures, for the protection of healers and relatives, that a third person is witnessing the visit. After the visit with the healer, the traditional coordinator is responsible to provide or arrange follow-up care to the client and the records are essential for this process. Providers, however, found that many relatives were guarded about their traditional health record, and often request that this information only be shared within a specific circle of care, such as the mental health team or the long-term care team. To respect confidentiality, traditional health records are kept physically separate, and information can only be accessed by those agreed upon by the client. The Noojmowin Teg approach to traditional healing services in a clinical setting has led to significant overall advancements in the integration of clinical and traditional approaches to mental health. During the interviews almost all clients expressed the belief that their workers are supportive of Aboriginal healing approaches, and that these services are accessible to clients. Service statistics show that community interest in traditional approaches to health is steadily increasing. This is an indication that more and more clients are comfortable accessing traditional services and sharing that information with clinical providers. Several clinical providers regularly inquire with each client about a referral to the traditional healing services. This development is particularly significant since a recent Canadian study showed that 92 per cent of Aboriginal people who use traditional medicine do not share this information with their primary care provider. In contrast, workers report that information about Aboriginal herbal medicines is openly shared in this service environment. For example an estimated 30 per cent to 40 per cent of those clients who receive care for geriatric or chronic mental health issues are also receiving traditional healing services. While some challenges certainly remain, the Mnaamodzawin Noojmowin Teg mental health team has made significant progress over the past decade in the development of an interdisciplinary team approach that includes both clinical and traditional Aboriginal approaches, with a particular focus on client choice related to services. The development of local guidelines, rooted in local culture, was an essential element for the successful integration of traditional and western services, because this protocol has alleviated uncertainties for clients and the interdisciplinary team of providers. Ongoing education for providers, as well as communities has resulted in improved understanding of traditional healing. Aboriginal and non-Aboriginal mental health team members alike expressed observing positive results in clients who accessed traditional healing. Many expressed a desire to increase the level of interdisciplinary collaboration, and believed this would be beneficial for their clients/relatives. Many also believed that increasing formal opportunities for collaboration would allow providers to further explore the congruence between the two healing approaches, and therefore improve treatment and healing approaches to the most prevalent mental health disorders. (Traditional Anishinabe Healing in a Clinical Setting: The Development of an Aboriginal Interdisciplinary Approach to Community-based Aboriginal Mental Health Care, Marion A. Maar, Ph.D., Assistant Professor, Northern Ontario School of Medicine, Laurentian University, Marjory Shawande, Traditional Coordinator, Noojmowin Teg Health Access Centre, Aundek Omni Kaning, ON, 2010) Traditional Healing and the U.S. Traditional healing and wellness have been incorporated in Canada within some hospitals and, more specifically, in clinical settings. The First Nations Health Authority (FNHA). FNHA is the first province wide health authority that was established in 2013. Noojmowin Teg Health Centre serves Anishinabek and Aboriginal individuals, families and communities within the District of Manitoulin Island. But what about the U.S.? In 2013, Sanford Health, centered in Bemidji Minnesota, hired Ojibwe and Lakota/Dakota traditional healers to train with medical staff for Sanford clinics in Minnesota, North Dakota, and South Dakota. Sanford is the largest rural, nonprofit hospital system with locations in 126 communities in seven states. The traditional healers would not necessarily perform traditional ceremonies but serve as consultants to existing medical staff, educating workers about cultural issues and also educating patients about their options for treatment. Through Sanford One Care, traditional healers would be brought in to join that patient’s health-care team. Currently, patients seek out traditional healing on their own.[3] The traditional healers also will work to link health-care providers with local tribes, so if a patient wants traditional healing services, clinical staff could meet that request.[4] The Mille Lacs Band of Ojibwe has integrated a traditional healing program. In 2000, Mille Lacs Band member, elder and Nenaandawi'iwed (traditional healer), Herb Sam, began working at the Ne-la-Shing Clinic. Clinics are located on the Mille Lacs reservation communities at Onamia, Lake Lena, and East Lake. Sam’s grandfather and father were traditional healers who worked with traditional medicine. Sam had seven mentors who helped him become a traditional healer. He said that receiving the gift of healing was long process. He supports modern medicine, but he also sees a need to incorporate traditional healing with what the doctors prescribe In addition to working at the Mille Lacs clinics, Sam also travels to Minneapolis where he helps Native Americans from all tribes, and he goes to people’s homes. [5] In his booklet, Sam writes: When the healer has completed his or her ceremony for healing, they may advise you that in order for you to feel better, you need to use a certain plant. The healer will explain how this will or should be done. The healer or the healer’s helper will give you the plant that has been prescribed and they will instruct you how to prepare it. If you have any questions, be sure to ask the healer, as some plants can be dangerous if they are not prepared properly. To have a good result in healing:
In 2016, visiting students from Dartmouth's Geisel School of Medicine met with Sam to learn about traditional health and healing. Sam explained how in contrast to Western biomedical doctors who rely mostly on their heads, his kind of doctoring comes from the heart. He spoke of the importance of listening to the wisdom that we receive in our dreams, and emphasized that he is merely a conduit for the healing powers of spiritual beings. He taught that diseases are like people, with their own spirits, their own agendas, and their own pasts, presents, and futures. Cancer, which is referred to as a “spider” in Anishinaabemowin due to the shape it sometimes takes when it spreads metastatically, should therefore be approached with respect and not hatred if it is to be healed. He advised that plant medicines be approached with utmost respect, and their permission should be asked before harvesting anything; ‘you don’t pick plants, plants pick you.’ Similarly, he advised the students to have respect for the power of pharmaceuticals and to learn the ins and outs of the medications that they would eventually be prescribing very, very well, in the same way that he cultivates intimate knowledge of, and relationships with, plants and other healing allies. While he had many words of wisdom for the students, his central piece of advice was to be a good human being, to work hard to truly heal and change yourself before you can heal others. He told them that while power is the currency of our modern society, there is an even greater force to be found in kindness, humility, and helping others without expectation of repayment. Finally, he assured them that if they had understood everything he had told them that day, his message would always be with them; that in a time of need they could call on him and his words, for they were now part of the medicine that lives inside their hearts.[7] Summary For me, to have a manidoowaadizi (spiritual nature) is the path that I try to follow on the Fourth Hill of Life. This doesn’t make me a medicine man or a healer. I am simply a maamawi’inini (common man) on a manijooshiwaapine babaamaadiziwin (cancer journey) who has absorbed the teachings of medicine people and elders to help guide me on this journey. And those teachings come from many years of listening and learning. Chi-Ma’iinganban (Larry Stillday) taught that the spiritual aspect is our inner essence, the part of us that exists beyond time and space and connects us to the Universal Source and the Oneness of Life. Developing our awareness of our spiritual level gives us the experience of a feeling of belonging in the universe and gives us a deeper meaning and purpose. Our spiritual aspect provides the foundation for the development of the three other aspects [Emotional, Physical, and Mental]. It develops our relationship with our selves, with our creativity, our life purpose, and our relationship with our Creator. Chi-Ma’iinganban also said: “We are the Ceremony. We are the ones we have been waiting for.” Each of us then is our own ceremony. And in that, I become the ceremony, I have been the one the ancestors have been waiting for. In my ceremony, I do those things that strengthen my jichaag (soul-spirit). I put my asemaa down, I smoke my opwaagan (pipe), I smudge with the Niiyo-Mashkikiwan (Four Medicnes) – asemaa (tobacco), wiingashk (sweetgrass), mashkodewashk (sage) miinawaa giizhikaandag (cedar) – and I carry those mashkikiwan with me as well. I dance(niimi) to nurture my jichaag. I listen to my bawaajiganan (dreams) that, in turn, provide me with waaseyaabindamowinan (life-guiding visions). I use my migizi-gwiishkoshichigan (eagle bone whistle) to offer healing prayers to those who walk the same journey that I do. My eagle fan holds the tears, pain, and suffering of those it has touched. This is my ceremony and this how I heal. Western medicine can remove my disease with surgery and chemotherapy, but it is the teachings and ways of my ancestors that heal my jichaag and provide a spiritual balance between two worlds. The other side for my healing is my role as a Native cancer educator/advocate. Why this role? Cancer survivors often ask “why me?” When I ask myself that question, the answer is that Gichi-Manidoo (the Creator) chose me for helping others learn about this disease. So my work and role is, in essence, a spiritual mandate. But the other side of that role is to help others, like health care professionals, understand who we are and how we use traditional approaches in our healing. My role also allows me to function as a member of the Makwa Doodem (Bear Clan). Inawemaagan Makwa (My relative the Bear) provides protection for the community. Throughout my life as a writer and artist, I’ve felt that I have been fulfilling my role as a Makwa Doodem member since my art and words have always focused on my people and, in essence, has been a way in which I protect my community by informing non-Ojibwe about my people. In addition, Makwa is also known as a medicine animal. Our ikwewag gete-aya`aag (women ancestors) were taught by Makwa many of the plants that were, and are, used for sicknesses and healing. Then there is my Ojibwe spirit name – Endaso-Giizhik. It means “Every Day.” As with many Ojibwe names, it may appear to be a simple name. However, Ojibwe names have context and meaning. When I was given this name, I was told it was an old name, one that reached back hundreds of years. It’s an Ogichidaa name, the name of a warrior who, each morning, roamed the outskirts of his village to look for any signs of the enemy. He was a protector. And when I was given that name, I was told that I too would be a protector, a protector of my community and my people. So all those elements – my personal ceremony, my clan, my name – compose who I am. It doesn’t make me special or significant. Rather, it’s what makes me a human being. Of course, I couldn’t relate any of that to my health care professionals. But I did have my eagle fan. My eagle fan represents of all those things. Like an Ojibwe name, my eagle fan has context and meaning. However, I couldn’t convey that to my doctors and nurses. Perhaps I didn’t have to. Perhaps they knew, through intuition, that my eagle fan was something larger than a cancer patient in a hospital bed recovery from surgery. And in this, it was the spirit within the eagle fan that touched them. A spirit of hope and healing on the cancer journey. I am the ceremony. I am the one that I have been waiting for. Works Cited: 1. Cultural Safety in New Zealand and the United States: Looking at a Way Forward Together, Dawn Doutrich, PhD, RN, CNS, Kerri Arcus, MA (Appl), RN, Lida Dekker, MN, RN, APRN, BC, Janet Spuck, MSN, RN, Catherine Pollock-Robinson, MN, RN, Journal of Transcultural Nursing, 2012. 2. The United States Does CAIR About Cultural Safety: Examining Cultural Safety Within Indigenous Health Contexts in Canada and the United States, Francine Darroch, PhD, Audrey Giles, PhD, Priscilla Sanderson, PhD, Lauren Brooks-Cleator, MA, Anna Schwartz, PhD, FNP-BC, FAAN, Darold Joseph, MEd, and Roger Nosker, BS, Journal of Transcultural Nursing, 2016. 3. Sanford Aims to Improve American Indian Health Care, Bethany Wesley, Bemidji Pioneer, January, 2013. 4. Partnership with Native Americans: Traditional Healers in Indian Healthcare, Andrew Bentley, 2013. 5. A Combination of Two Worlds, Mille Lacs Messenger, Diane Gibas, 2015. 6. A Little Background on Traditional Health, Herb Sam, Mille Lacs Band, January 7, 2014. 7. Mino-Mashkikiwan: Good Medicine, May 17, 2016. © All Rights Reserved, Robert DesJarlait, 2017
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Robert Desjarlait
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