Nursing with indigenous communities: The question of membership

Membership and belonging are important factors for well-being on an individual level. It is a topic that resonates strongly with me for a long time. In 2004/05, I have written an article on community membership and belonging from a nursing perspective with a particular focus on cross-cultural practice in indigenous communities. It was never published, but might be of interest to some.

Nursing practice with Aboriginal communities: An exploration of the question of membership.

Othmar F. Arnold, RN, MN,

Abstract

For most nurses working with Aboriginal people, such a posting is a professional challenge. Nurses do not hold any formal membership in the cultural and ethnically diverse communities they serve. The importance is placed on competent and efficient delivery of needed services for populations that are known for significant health disparities and marginalization. Drawing from Nuu-chah-nulth origin stories, it appears to be important for the realization of Aboriginal health, healing, and well being that health professionals acquire community membership. The difference between the two world views poses an ethical dilemma, possibly constituting a form of cultural imperialism. Nursing science based approaches for bridging the intercultural gap are explored.

Health Centre, Carmacks, Yukon, serving the Village of Carmacks and the Little Salmon/Carmacks First Nation

Content:

Membership from an Indigenous Perspective

Membership from a Discussion among Community Nurse Practitioners

Membership from a nursing theory perspective

Ethical questions

Recommendations for action at micro, meso, and macro level
Nursing in Aboriginal communities is usually advertised by the employers with much reference to getting to know different cultures and the lifestyle opportunities a posting in the North or in a remote community brings. The other realities of these picturesque settings described in reports such as the one from the Royal Commission on Aboriginal Peoples (1993; 1996) are not being mentioned. For nurses and other health care providers, considerable diversity exists in motivations and interests that lead to the individual career choices and the related decision about the particular work place settings. The employers, essentially the federal government, have an obligation to provide health services arising from century-old treaty promises made during the colonization of the continent. Before contact, the diverse Aboriginal populations had their own systems in place that provided for the health and well-being of individuals and communities.

My own theoretical inquiry into the differences between Aboriginal perspectives of health and the dominant discourse that forms the basis for the delivery of health services identifies the question of the provider’s membership in the community as an important aspect that would contribute to health and healing from an Aboriginal point of view (Arnold, 2005). The issue of such membership is not discussed in the scholarly literature and does not appear as a concept in the Western world view. This led me to query whether there is a largely unrecognized ethical dilemma, embedded in the way health services are being delivered to Aboriginal communities.

In this article, I will explore the concept of membership in the community for nurses and other health professionals from three perspectives. I will first locate the topic in the literature, starting with an Aboriginal perspective, then I will summarize the views of nurses who practice in Yukon communities, and will finally explore it from a nursing theory perspective. Nursing science may offer a way to narrow the perceived intercultural gap. I will further discuss the issue of membership as an ethical question. In the last part of the article, I will formulate various recommendations for addressing the issue with the goal of being able to make a positive contribution to the long term health and well-being of  Aboriginal communities.

Membership from an Indigenous Perspective

As ethicist Janet Storch (2004) states, “nursing ethics is about being in relationship to persons in care. The enactment of nursing ethics is a constant readiness to engage our moral agency” (p. 1. This statement captures a deep essence of nursing practice, but it also reveals significant cultural roots of the nursing profession. Based on Richard Atleo’s (2004) assessment of the differences between Western and indigenous thought, he claims that separations, such as the ability to practice while being ready to engage moral agency, are a fundamental characteristic of Western thought. In his native Nuu-chah-nulth world view, the most fundamental principle is heshook-ish tsawalk, meaning “everything is one” (p. xi). Therefore, in his understanding of the world, nursing ethics cannot be enacted, moral agency cannot be engaged, it must be lived. For the Nuu-chah-nulth, there is an experiential continuum between the physical and metaphysical worlds.

First, I will examine the question of membership from an indigenous perspective. I will use Richard Atleo’s (2004) book Tsawalk as my source of reference. This monograph of a Nuu-chah-nulth world view, largely based on origin stories as told by elders of the nation and recorded by Atleo, a hereditary chief of the Nuu-chah-nulth and Western-trained scholar, does not represent the full spectrum of indigenous world views. However, this world view exemplifies some fundamental characteristics that are found in many indigenous belief systems (Spector, 1996). Therefore, Atleo’s work serves as a unique example which illustrates some common distinctions between Western and indigenous thought.

Membership emerges as a central theme in some of the Nuu-chah-nulth origin stories. I will first summarize Atleo’s writing on that topic. Then, I will expand and discuss other, less explicitly stated forms of membership that are contained the origin stories. In the second part of this article I will present ideas about membership from nurse practitioners that practice in predominantly Aboriginal communities in the Yukon.

In the Nuu-chal-nulth world view “the Creator and the created, the Creator and creation, are intimately related in thought, word, and deed” (Atleo, p. 34). However, he also describes boundaries that need to be observed. Membership in one community, be it a spiritual one or a human one, does not automatically provide membership in another one. Rights can be acquired and they are tied to purpose, as Atleo illustrates using the example of two important figures in Nuu-chal-nulth origin stories: On one side, there is Aint-tin-mit, the Son of Mucus, who is a spiritual being that came into the human community of Ahous (an abandoned Nuu-chah-nulth settlement on Vargas Island, British Columbia). He is a mediator of life. He is regarded and celebrated as a hero and rescuer in the community. His antagonist is Aulth-ma-quus, the Pitch Woman who lives near the village in seclusion. She is seen as the destroyer of life, the one who steals children from the community. Atleo never put these two characters directly into a health context, but Aint-tin-mit emerges as healer, while Aulth-ma-quus would represent disease. In the Nuu-chah-nulth world view, health and well-being in general are conceptualized as harmony and balance, something that people have to seek through intentional choices and that is driven by the tension between opposite forces.

Aint-tin-mit was born into the community through the mucus of the chief’s wife. This grants him community membership despite his foreign (metaphysical) origin. But his community membership is also defined through his actions and purpose. He sustains that membership through cooperation with the families and the community, through his heroic rescue of the abducted children from the home of Aulth-ma-quus, and quality of relationship with the members of the community. On the other hand, Aulth-ma-quus resides near the community long before Aint-tin-mit is conceived, but she is not regarded a community member because of her alienation, her isolation, and her strong relationship to technology (Atleo). Her lineage and common ancestry with the community are not qualifying her for membership because of her actions and purpose, which are destructive and evil. However, she remains part of creation and as such part of the wholeness of the universe.

In his analysis, Atleo emphasizes birthright and legal membership as important elements for forming community. While birthright is tied to lineage, legal membership appears to be an ethical category. The term legal does not refer to a distinct code of agreed upon rules such as the common law or the civil code legal systems. It relates more to ethical principles as they are understood as the foundation of life in the Nuu-chah-nulth world view. Aulth-ma-quus has no legal right to membership because she opposes balance and harmony; she is seen as an enemy to life, family, interrelatedness, and wholeness (Atleo). Legal membership in the community cannot be understood as an administrative category, but as an outcome of relationship between the individual and the collective and its contextual meaning within the scheme of creation.

Birthright is not equated with becoming a citizen in contemporary terms. Lineage and ancestral territory constitute a system within a larger universe; birthright is an expression of embeddedness in such a system. It is not defined in terms of rights and responsibilities, but in terms of beneficial reciprocity, which again points out the relational characteristics of interrelatedness versus the autonomy of the individual.

Getting married is another important form of relationship in Nuu-chah-nulth origin stories that will lead to membership. Marriage is not the sanctioning of legal rights in respect to property, custody of children, etc for two individuals – a contractual arrangement – but an affirmation of mutual recognition, mutual respect, and mutual responsibilities between earthly and/or spiritual communities: it “is the formal expression of the general characteristic of creation, which is relationality” (Atleo, p. 49). As with membership in the community, marriage requires a lifetime of preparation by learning about the principles of creation, the depth of the knowledge contained in the origin stories, and the protocols that provide guidance for many decisions on an individual or collective level. Nuu-chah-nulth marriage was often an intertribal affair and was celebrated after a determination through tests and trials that it was mutually beneficial and sustainable.

Atleo’s description and analysis of the Nuu-chah-nulth world view does intentionally not follow a Western framework; it is an attempt at formulating an indigenous discourse. It appears therefore not systematic and it becomes difficult to find a precise and exact description of a concept such as membership that matches the Western assumptions. I find it fascinating to embrace the richness of the stories and the challenge of bridging the differences between a unitary-transformative and a particulate-deterministic paradigm, between the various ontologies and epistemologies associated with the two worldviews. I will now leave the unfamiliar world of the Nuu-chah-nulth and will return to the more familiar world of community nursing in Canada’s north. Towards the end of this paper, I will refer back to some of the principles gleaned from the Nuu-chah-nulth origin stories.

Membership from a Discussion among Community Nurse Practitioners

In April 2005, I had the opportunity to use advanced telecommunication technology to facilitate a continuing education workshop with community nurse practitioners in the Yukon. Using the Telehealth network that links all the nursing stations and health centres in the various rural and remote communities in the Yukon with a hub located at the Whitehorse General Hospital, I was able to present the findings of a theoretical inquiry I did titled “Working in Aboriginal communities: What kind of health are we promoting?” (Arnold, 2004). In this study, I conclude that membership is an important element of harmony and balance, and therefore of health and healing, from an Aboriginal point of view.

After the presentation, I invited the attending nurses to engage in a previously announced discussion about their view of community membership of the health professional. Seven community nurse practitioners from four different locations, hundreds of kilometers apart, took part in the discussion. They were informed about my intention to use their contributions for further exploring the question of membership or nurses practicing with Aboriginal communities. I received verbal consent over the Telehealth videoconferencing system. All participants had extensive experience practicing in various remote settings across the Canadian North and the provinces, serving predominantly Aboriginal populations. The participants were also familiar with the Internet-based technology which is primarily used for clinical consultations and which has the capacity for video, voice, and data transfer.

Initially, the discussion evolved around ethnicity. All the participating community nurse practitioners stated that they were not from the Yukon and do not have Aboriginal ancestry. Based on the notion that membership in an Aboriginal community is tied to the most commonly known form, the band membership, all participants declared that they had no membership in the communities they serve.

Band membership is a controversial form of membership among Aboriginal populations. There are significant benefits attached. It derives from the definition of Indian status in the federal Indian Act (1985). This status is not universally granted to all people of First Nations ancestry. Historically, Indian status was only granted under strict conditions, based on blood relationship and residency on a reserve. However, some Aboriginal groups did not qualify the formal requirements to become a band under the Indian Act. Other groups and individuals became excluded from acquiring status or forfeited their status because they chose not to reside on a reserve or married into the dominant society. Many benefits, including the provision of health care, are contingent on band membership or Indian status. The distinction between status and non-status Indian is not maintained in Part II of the Canadian constitution. In Section 35, which defines Aboriginal rights, paragraph 2 specifies Aboriginal collectively as the Indian, Inuit, and Métis peoples of Canada (Constitution Act, 1982). No particular membership other than belonging to one of the three categories can be derived from there.

The discussion then focused on the issue that there are not many trained nurses with Aboriginal ancestry in the system. Some of the participants have worked with Aboriginal nurses before. One nurse mentioned that it seems very difficult for Aboriginal nurses to return to their own communities to practice because of various social pressures and expectations. One aspect that was reported was the difficulty of practicing according to professional standards without violating cultural protocols and taboos. Physical examination as it is standard practice in nursing may not be appropriate across gender barriers and clan membership for a member of the community. The nurses compared the situation to caring for a close relative. This can personally be very awkward for the nurse and the client. It is also professionally considered as a conflict because the personal and professional relationships cannot clearly be separated (Registered Nurses Association of BC, 1994). Another ethical dilemma that was mentioned was whether a nurse can freely socialize and participate in community activities. The loss of credibility that may occur for the nurse when living, socializing, and working in a community where many lifestyle choices may not be congruent with professional discourses.

This dilemma holds true for non-Aboriginal nurses. Several participants mentioned that they refrain from socializing within the community of their posting. Their social and cultural needs are met during visits to the capital city or during vacation time in their home community. For most of the nurses, this is a key limitation for a long-term engagement in remote communities and with Community Nursing as an employer. The membership statistics from the Yukon Registered Nurses Association clearly indicate a very high turnover rate of nurses employed in the Yukon: Half of the registrations each year are from new registrants.

The participating nurses were hesitant to state that they were members of their respective communities. First, from their own point of view, they qualified themselves on a spectrum from transient to resident. The responses corresponded closely to the number of years of service and to the employment status. A significant number of community nurse practitioners are hired for short term relief, with postings ranging from weeks to several months in duration. The majority of participating nurses work full time for the Yukon Government. Three of them have served for several years consecutively in the same community. Although residency was acknowledged as a possible form of membership, it was not seen equally strong as membership in the sense of citizenship (the legal status evolving from band membership for members of self-governing First Nations), ancestry, or cultural and ethnic belonging. The social limitations mentioned above are one of the main reasons why nurses who live and work for years in Aboriginal communities continue to consider themselves at home elsewhere. Interestingly, none of the participating nurses own property in the community they live and work. This observation seems to illustrate the distance in relationship.

On the other hand, the participating nurses also stated that they are not considered as full members by the community they serve. The length of service or the intensity of engagement in community activities by the nurse does not seem to influence that perception. One participant speculated that this may need to be seen in a historical context. Health care was until recently delivered under the authority of the same government administration that was being recognized as the oppressor by Aboriginal peoples. This nurse participant suggested that after the devolution of the health portfolio to the Yukon government the delivery of health care has a less strong association with the unfavourable image of the Department of Indian and Northern Affairs Canada. However, the healing of these historical wounds may take a long time to heal.

Nurses and health centre staff learning together about indigenous ways of knowing during a cultural immersion day in Cambridge Bay, Nunavut

In the course of the discussion, the participants mentioned that membership could also be seen as a relationship. All participants agreed that they are able to develop good relations to the community and the population they serve without qualifying for any formal membership. Some nurse practitioners stated that membership makes no difference on the effectiveness of delivering health care services. The significant factors are experience, competency, knowledge, and strong organizational support from the employer.

Based on the limited data collected during this discussion, several notions of membership emerged: The strongest ones in a legal sense in the form of citizenship and registration. The second one is seen in form of blood ties or as a genetic expression. The next notion is based on residency and involvement in common activities. This could be categorized as relationship-based. The last one is more esoteric: It includes a sense of belonging, the notion of identity, and other hard-to-define perceptions of being a member. In the next part of this article, I will examine the notion of membership from a nursing theory perspective.

Membership from a nursing theory perspective

In the context of nursing, membership is discussed in conjunction with the registration process or a professional organization. Several web searches using search engines and databases of scholarly journal articles were unproductive in locating any resource that would associate the professional world of nursing with community membership in the sense discussed above. Related searches, using the terms ‘cultural’ and ‘belonging’ brought different results, one stream pointing out how education and practice in nursing contribute to the practitioner’s belonging to an accultured group. The other one produced results that captured cultural belonging as an element attributed to a client that can be assessed by a nurse. The one study that stood out by taking a reflective look at the professional nurse and nursing as a profession was by Reimer Kirkham (2003). In this article, Reimer Kirkham describes how people from various cultural groups, both among health care professionals and clients, are relying on cultural differences as scripted in the national discourse of multiculturalism to keep the distance from each other. Membership is seen as exclusive along noticeable differences and impacts the nurse-client relationship unfavorably, further exacerbating structural inequities and marginalized statuses. Reimer Kirkham argues that alliances need to be built across many identities in order to contribute to a more inclusive health care system. Although this article did not advance my quest for defining membership from a nursing theory perspective, it helped me find a new approach: Instead of dwelling on the differences, a solution needs to be sought among the similarities.

Nurses who belong to a particular cultural group or a professional culture relate to specific values of that group. The sharing of the same or similar values appears to be an essential element for the sense of belonging. Belonging itself can be seen as membership, but it is one-sided unless there is a formalized or institutionalized process for awarding or recognizing it. However, the awarding of formal membership can also occur without the sense of belonging. Professional membership is a transactional process: Subsequent to the assessment of credentials, competencies, and the payment of fees the benefits of membership in the form of rights, privileges, and responsibilities are bestowed upon the member. Membership is maintained through observing the minimum conditions attached to the responsibilities – often as simple as recurrent fee payments – and by not getting in obvious conflict with professional standards and rules.

The transactional character of membership is in stark contrast to the relational character emerging from the Nuu-chah-nulth world view and the conclusions from the Reimer Kirkham article. Hence, I will focus on the notion of relationship for synthesizing a possible answer to the question of membership in intercultural settings.

The concepts of relationship and relational practice are much better represented in the nursing literature than the concept of membership. A therapeutic relationship is a basic element of nursing practice, often considered the essence of nursing; there are various nursing theorists that build their theories directly on the nurse patient relationship: Peplau, Orlando, Travelbee are some of them (Alligood & Marriner Tomey, 2002). Other theorists built their nursing theories on the actions from or expressions of relationship: Leininger is the foremost proponent of caring as the central theme of nursing practice. Her theory is one of the more influential ones in an intercultural context because it speaks directly to transcultural nursing (Alligood & Marriner Tomey). The nursing theories by Parse and Newman describe a different form of relationship based on Rogers’ conceptual model. Her science of unitary human beings is grounded beyond the positivism of the classic sciences. Relationships are expressed through terms such as resonance, field dynamics, mutual processes (Alligood & Marriner Tomey). In particular Parse’s nursing theory that builds on Rogers’ model and proposes nursing as a discipline in its own rights within the human sciences helped me develop an understanding of relational membership that could serve as a starting point for an expansion of the above discussion.

The traditional nurse-client relationship, a skill or a tool for the practicing nurse that can be developed from a novice to an expert level, appears to be conceptualized along a gradient. There is a clearly defined giver and a receiver. Furthermore, the nurse-client relationship is embedded in a health care system that is built on a hierarchical structure. On the other hand, a human science approach defines both nurse and client as equivalent, open energy fields that need to resonate in synchronicity. This mode of practice leads to the co-creation of the process of becoming, more commonly known to us as health (Parse, 1998). Because many nurses are unfamiliar with the philosophical assumptions of Parse’s theory, it is difficult to discuss or apply it directly in a mainstream context.

Relational inquiry and practice is proposed by Hartrick Doane and Varcoe (2005) as health promoting practice. This text emphasizes the relational aspects of nursing as more than facilitating the provision of care. It challenges the medical model that is able to isolate a problem and find a cure. Relational practice is all about context, seeing the client in their larger sociopolitical, cultural, economic, and environmental circumstance. And it includes the nurse as part of the context, which makes it possible to critically reflect on the nurse’s doing and being within that relational practice. Although the authors seem to maintain the more transactional aspects of relationship, their conceptualization is much closer to a unitary understanding than the therapeutic nurse-client relationship based on a Cartesian view. I personally do not see any aspects of membership relevant to the discussion at hand in this paper attached to the latter one, although it might be possible to construct some imposed ones. I think this is an important aspect for the discussion of the ethical questions around the issue of membership that will follow.

Ethical questions

The ethical dilemmas arising from the divergent expectations in Aboriginal and the contemporary health care culture about membership of the healer in the community is difficult to discuss because of its subtle nature. It is not about a life and death situation, a controversial advanced technology, or a question of individual human rights. The four classic principles of biomedical ethics are not directly applicable, due to the lack of clearly identifiable actions with a cause and effect relationship. It is also not directly a matter of the individual nurse-client relationship, an area that Lamb (2004) has identified as the basis for ethical conduct for the future of nursing ethics. Many of the issues of biomedical ethics are centered around the individual, or egocentric. They are linked to the trajectory of illness or disease within the individual. The nursing ethics presented by Brown, Rodney, Pauly, Varcoe, and Smye (2004) is more socio- or ethnocentric. It includes a context of ecological, social, economic, political, and cultural influences on the individual. The question of membership seems to belong to a broader sphere. It appears to be located in the realm of collective consciousness and to be based on worldviews.

So far in this article, I have provided evidence that at least in the Nuu-chah-nulth worldview, membership in the community is an important aspect to health and healing, not just from an individual perspective, but from a broader community or population perspective as well. I assume that the importance of the membership of the healer or health care provider holds comparable status in many other Aboriginal health belief systems. The central themes of membership emerging from Atleo’s (2004) text on the Nuu-chah-nulth world view are intentional relationship, reciprocity, and committed continuity. Aint-tin-mit chose to serve the community to restore harmony and balance, acquired birthright, and committed again to the community by preparing for marriage, a relationship between two individuals, as well as between respective houses or communities. In the origin stories, Aint-tin-mit exemplifies the two central themes of membership, while Aulth-ma-quus represents the opposite (Atleo).

I have also shown that most health care providers in Canada’s Aboriginal communities today are employees of governments or health authorities. They are predominantly serving for limited time periods, ranging from weeks to many years, in their postings. Very few of the providers eventually adopt and consider their postings as home. A large number of nurses considers working in Canada’s North and in an Aboriginal community as a temporary challenge beneficial for their professional growth and as a part of their career development without a long term commitment. Some of the nurses I discussed the topic with consider themselves partial members of the Aboriginal communities they serve. Many of the nurses working with Aboriginal communities are motivated to do so to some degree by the obvious health disparities and the urgent need for services derived thereof. In their attitude, I sense moral courage in their commitment to serve in remote places and under difficult circumstances. It seems that nurses bring intentionality to their work in Aboriginal communities, but do not necessarily integrate that with building a reciprocal relationship and commitment. Continuity is mainly provided by maintaining the delivery of services by the responsible agency.

In the third part of this article, I have elaborated on theoretical aspects of membership from a nursing science point of view. The definition of the classic nurse-client relationship opposes the notion of acquiring membership in any client group at the level the Nuu-chah-nulth example of an Aboriginal health belief describes. However, there are nursing theorists who offer approaches that could lead to the development of new options towards becoming a member of a community without the unachievable citizenship or belonging in an ethnic sense. A new form of membership for health professionals would have to be framed, particularly in the context of health and healing, based on qualities exemplified in the origin stories cited by Atleo (2004). Some of the nursing theories are conceptualized on a strong relationship between the nurse and the provider that clearly includes reciprocity and transcends the classic framing of the therapeutic, professional relationship. Parse’s (1998) model is one that exemplifies intentionality and reciprocity. It could also be used as the basis for an argument for continuity.

Knowing that there is that substantial difference in worldviews between an Aboriginal culture like the Nuu-chah-nulth and the culture of health care in contemporary Canada, particularly as delivered over time to Aboriginal communities, left me with some serious questions. Are nurses, as health care professionals, imposing a view of health and an associated delivery system on population groups that might not contribute to the health and healing of said groups? This resembles the challenge Rodney, Pauly, and Burgess (2004) describe for the field of health care ethics: Is it a form of cultural imperialism?

Another aspect of cultural imperialism may be expressed in the fact that membership for health care providers in the community they serve is not a topic that is discussed to any extent in the scholarly literature. It points to the issue that the dominant culture is not recognizing the worth of other cultures’ resources for ethical practice. Recognizing and genuinely accepting the existence of diversity in health belief systems between the two cultures could be a first step towards “a cross-cultural dialogue on the nature of ethics and the goals of health and health care”, as suggested by Rodney, Pauly, and Burgess (p. 83).

Based on the acceptance of the initial premise (the existence of diversity and the possibility of cultural imperialism), more ethical questions can be formulated: Has the frustration experienced by health care providers working with Aboriginal groups, based on the perceived lack of progress in moving towards better overall health, possibly a connection to the fundamental differences in the worldviews and the understanding of health between the two cultures? Could the ever increasing demand for and deployment of resources towards improving Aboriginal health without significant corresponding visible or measurable positive changes in health status be an indicator that the current approach of delivering health care has some fundamental flaw that goes unrecognized? Is it ethically justifiable to continue to practice based on largely unchallenged assumptions imposed from a dominant discourse on a marginalized population? What idea or actions can we take to steer towards a moral horizon based on the above dilemmas? It is not possible to individually discuss all the above questions in detail within the scope of this article. However, I will formulate some recommendations based on the overall analysis and discussion that could contribute to a more ethical intercultural practice in the last part of this article.

From an ethics point of view, one of the fundamental dilemmas is located in the application of the autonomy principle. Health care is delivered to autonomous individuals. The autonomy principle incorporates, in a conventional sense, sufficient competency, the capacity to understand and make reasonable choices (McPherson, Rodney, McDonald, Storch, Pauly, & Burgess, 2004). It was the lack of recognition of these competencies and capacities in Aboriginal people by the colonial masters that formed the foundation for the creation of the Indian Act and the contemporary model of health care delivery in Aboriginal communities. Furthermore, the Western thinking is so saturated with notions of individualism that up to this day unitary models and worldviews are either dismissed or marginalized. This is evident in the discussion around the validity of the definition of health as expressed in certain Aboriginal cultures, which has no focus on disease or individual perfectioning of the body and mind, but expresses health as ‘being alive well’, which includes a broad understanding of meaningful relationships with the environment, as well as with the social, political, and economic contexts (Adelson, 2000).

Delivery of health care as a service makes sense in a society that is based on individualistic thinking and consumerist economic principles. Accordingly, the health care system is staffed like a business venture based on transactional principles. Hence, for the administration it is sufficient to know that a particular position is staffed to maintain continuity of operations. It makes no difference to the system whether a position is filled with a nurse who has engaged in a long term relationship with the community or a temporary relief nurse who brings the minimum qualifications according to the job description.

From the discussion above it becomes evident that delivering health care to Aboriginal populations is predominantly a transaction of services. Health care is provided on scientific evidence that is largely derived from medical and social sciences. Spiritual aspects of healing are not within the scope of science and most professional discourses. They are considered within a person’s private sphere (Arnold, 2004). On the other side, from an Aboriginal perspective, health and healing is a matter of relationships with the healer, the community, and the universe. It incorporates metaphysical as well as physical aspects that cannot be separated into the private and public realm. The separation of the private and public or professional spheres is an important premise for defining the classic nurse-client relationship.

As I have already demonstrated in conjunction with the nurse-client relationship, the application of universal, abstract principles, which form much of the basic understanding of Western science, has very limited applicability. A principle based ethics discourse that continues to inform many ethical decision making processes in the health care system has been questioned by various postmodern thinkers (Johnson, 2004). In the Nuu-chah-nulth world view, the emphasis is more on protocol than on principles. Protocols are observed processes that guide the interactions between various realms and life forms. These realms can be either in the physical world or the metaphysical one. According to Atleo (2004), protocols are neither universal nor static: they are intimately tied to and inseparable from local context, passed down orally over generations without the need for an authoritative form in the sense of a written historical record, and contain illustratively important cultural principles and values. These protocols have clearly an ethical dimension: Because the undivided universe in its original state of interdependence of a variety of life forms is considered the ultimate moral authority of this world view, the protocols guiding those interactions and relationships need to be seen as the relevant principles for ethical discourse in Aboriginal communities.

In nursing ethics, care-based discourses find abstract principles equally irrelevant, ineffectual, and constricting (Brown, Rodney, Pauly, Varcoe, and Smye, 2004). Instead, nursing ethics focus more on the quality of the relationship and the role of emotions in choosing a path of ethical action. One of the promising perspectives in the discussion of nursing ethics is the reflection on social conscience. In combination with nursing science based on unitary-transformative theory rather than particular-deterministic principles, nurses will have the capacity to narrow the intercultural gap that defines the difference between delivering health care to Aboriginal communities and working towards healing with Aboriginal peoples. Intentional and reciprocal relationships are theoretically on the horizon for nursing practice. Committed continuity will need a much larger paradigm shift on the structural and sociopolitical levels.

Recommendations for action at micro, meso, and macro level

Membership in a community for the purpose of healing as suggested from the Nuu-chah-nulth origin stories cannot be mandated, legislated, or regulated. The central themes emerging from Atleo’s (2004) text, intentional relationship and committed continuity, are not skills that can be taught and learned through an educational process. They must be lived or embodied. Therefore, it will take a paradigm shifts at the individual and collective levels to move closer to resolving the discussed ethical dilemma.

Based on the discussion of the issue in this article I suggest the following recommendations for action: At the micro level, more attention needs to be spent to the staffing of positions for nurses delivering health care services to Aboriginal communities. A nurse is not simply replaceable with another nurse with a comparable set of competencies, because nurses do form valuable relationships with the community they serve. This accumulated and embodied knowledge is not subject to transactional rules that can be applied to other assets in the health care system. My first recommendation is therefore to improve staffing processes in order to foster long term engagement of the health care providers with the communities they serve. The second recommendation at the micro level relates to the idea that human resources attracted from the respective communities may be more connected to them. This would result in a more stable and consistent work force within the existing system. However, particularly for the Aboriginal communities in Canada’s North, it cannot be expected that members of the community will necessarily be attracted to the educational and training opportunities that are so far removed from their communities. Therefore, the development of human resources for the local health care system needs to be brought closer to ‘home’ and potentially the academic requirements reconsidered. Is the Master’s trained nurse practitioner the only possible solution to meeting the comprehensive health needs of Aboriginal communities?

At the meso level, my suggestion is to further develop nursing theory that supports the redefinition of the nurse-client relationship. A broad discussion with the regulating bodies in nursing, the political bodies that represent the interest of the public, and the nurses and communities needs to take place. Eventually, the goal would be to revise practice guidelines and standards that limit the expansion of the nurse-client relationship towards that of a community-based healer.

At the macro level, my recommendation is to abolish the Indian Act and hence negotiate the release for the federal government from its centuries-old obligation to provide health care services to Aboriginal peoples. Significant constitutional, legislative, and policy changes would be required to reverse the colonial effects of the current health care system and to allow the development of approaches to health at the level of individual nations or Aboriginal peoples based on their respective health belief systems without the necessity to conform to federally dictated norms that currently triggers the release of significant fiscal resources.

Conclusion

Changes based on these recommendations could lessen the impacts and consequences of the ethical dilemma in relation to community membership derived from paradigmatic differences between Aboriginal and health care cultures. It will not be possible for all the nurses and health care providers to acquire the same level of membership in the communities they serve as Aint-tin-mit did. However, substituting this form of membership can be achieved by taking steps towards intentional relationships, reciprocity, and committed continuity will reflect principles of nursing ethics and will contribute to the much needed healing for Aboriginal peoples in a postcolonial world.

References

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