Margaret P. Moss, a member of the Mandan, Hidatsa and Arikara Nation, is a nurse, a doctor, an attorney and a writer who has combined her skills to compile the first nursing textbook on American Indian health.
She and twelve contributing authors guide readers through the implications for nursing care of nine distinct Native cultures. She describes how disparities in health care policy, as well as environmental, historical and geographic conditions have led to poor health for so many American Indian and Alaska Native people. Springer Publishing Company has scheduled publication of American Indian Health and Nursing for December.
Moss says she learned cultural competence on the job because no formal material on American Indian health and nursing was available. She has made it her mission to teach her nursing students what she had to discover on her own. In this textbook, she shares that information with a wider audience of medical students and professionals and with anyone who has an interest in American history, current American Indian issues and health and healthcare.
Moss talked with ICTMN about health care in Indian country.
Could you talk about how a lack of cultural competence among health care providers contributes to health disparities in American Indian and Alaska Native populations? What are some of the characteristics of cultural competence?
Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, an agency or among professionals that enable that system or agency or those professions to work effectively in cross-cultural situations.
[In the health care industry] there are many historical, political and geographic realities for American Indians that feed into the social and structural determinants of health that are largely “unseen” by non-Natives, who want to know, “Why can’t American Indians just become healthier?” And that is if they know the health circumstance of Natives at all!
We now know that due to historical trauma—unresolved grief—epigenetic changes absolutely do occur, changing today’s American Indian people’s physical, mental, emotional and spiritual responses to the circumstances they find themselves in.
If the health care provider and the health care system do not recognize how past atrocities and current circumstances manifest into today’s health picture for American Indians, then it will be hard to change the incidence of disease and mortality.
If people are pushed out to unfarmable land, if they are 100 miles from the nearest “real” grocery store, if they must travel hours to the closest IHS hospital, how would anyone do? Throw in no money, less education and fewer income opportunities, hopelessness, rampant methamphetamine use and alcohol abuse. If [you were a nurse and] this was your patient’s reality, would you just give normal diabetic education and discharge instructions?
Another example—as nurses we learn most about physical issues that require our intervention, although as nurses we also embrace a holistic view of the person. So we should recognize mental and spiritual aspects [of illness] as well.
Elderly, traditional American Indians, for example, have a similar view of the person as nurses do, but probably in reverse order. Spiritual life is first [in importance] and physical [condition] last. Unless you know this, you may not be planning care in a culturally competent way. If you are pushing your Western, one-size-fits-all plan of care you will not be optimizing the health of the person in front of you.
The other problem is that [as a nurse] you often don’t KNOW who is in front of you, especially in urban areas. Misidentification is a huge problem in providing culturally competent care and implementing the Affordable Care Act’s mandates for patient-centered care. No one ever asks… people usually don’t expect to “see” an American Indian in their clinic. And if they do, they may not know, unless they ask.
What are some of the things that could be done to increase the number of AI/AN practitioners in the nursing profession? Is that important?
It is critical that we increase the number of American Indian nurses. When the nurse is an American Indian, there is shared history and understandings with the American Indian patient, whether on the reservation or in urban settings. They are experts in the culture and the experience and they can bring that expertise to the profession. Insight into patient care will increase and the discordance between American Indian patients and [health care] providers will lessen.
What are some of the unique factors nurses must understand in order to treat Indians in urban settings effectively?
Urban identity is a heterogeneous mix. People [went to the cities via] military service, education and employment routes. They also got there in the mid 1950s because of Indian relocation programs that promised housing and jobs to Indians if they moved to cities, with the goal of assimilation. The housing and jobs were rarely as promised, if they existed at all.
Intertribal identities come to the fore in urban areas in contrast to the mostly singular tribal identities “back home.” Therefore, when [city dwellers] return to their reservations reintegration may be an issue. The two worse case scenarios are the highly visible homeless American Indian in the cities and the invisible American Indian on the reservations. Either bookend of this experience is destructive. Again, correct identification is one of the biggest services nurses in cities can provide.
Moss holds a Ph.D. in nursing from the University of Texas-Houston and a doctorate of law from the Hamline University School of Law. She began her career as an inpatient clinical nurse and patient educator in 1991 when she took a position at the Indian Health Service’s Santa Fe Indian Hospital. In 1999, she was awarded a National Institutes of Health grant for her dissertation on the Zuni Pueblo, in which she explored why elders would not seek eldercare and found the answers deeply rooted in tradition, culture, medicine and religion.
She has taught and pursued her research interests at the Yale School of Nursing, McGill University, the University of Minnesota, and as director and principal investigator of the Native Nurse Career Opportunity Program and as faculty on the NIH Bridge to the Ph.D. program at the University of New Mexico. Currently she is Assistant Dean for Diversity and Inclusion and an associate professor at the State University of New York–Buffalo, School of Nursing.