'In our culture, we come when you die': Qualitative descriptive analysis of end-of-life perspectives in a reservation-based community.

AIM: To explore (1) perspectives and attitudes of Native Americans regarding transitions from serious illness to death, and (2) awareness about hospice and palliative care service models in a Great Plains reservation-based community. DESIGN: Qualitative descriptive study. METHODS: Community members and clinicians were invited to participate in a semi-structured focus group or interview by Tribal Advisory Board members. Analysis involved three phases: (1) qualitative descriptive analysis of preliminary themes using the Addressing Palliative Care Disparities conceptual model; (2) a cultural review of the data; and (3) reflexive thematic analysis to synthesize findings. RESULTS: Twenty-six participants engaged in two focus groups (n = 5-6 participants in each) and interviews (n = 15). Four themes were derived from their stories: (1) family connectedness is always priority; (2) end-of-life support is a community-wide effort; (3) everyone must grieve in their own way to heal; and (4) support needs from outside the community. CONCLUSION: Findings highlight cultural considerations spanning the life course. Clinicians, researchers and traditional wisdom keepers and practitioners, particularly those working in rural and/or reservation-based settings, must provide culturally safe care. This must include acknowledging and prioritizing the needs and preferences of Native American patients and the impact on their families and communities. IMPACT AND IMPLICATIONS FOR THE PROFESSION: Leveraging community assets, such as family and social networks, is key for supporting Native American patients with serious illnesses. Additionally, facilitating greater family and caregiver involvement along a patient's care trajectory may be a pathway for easing health care workers' caseloads in reservation-based areas, where resources are limited. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was used. PATIENT/PUBLIC CONTRIBUTION: The study was ideated based on community insight. Tribal Advisory Board members oversaw all aspects including recruitment, data acquisition, interpretation of findings and tribal data dissemination.

The path to development of the Hózhó Resilience Model for nursing research and practice.

This article describes how the Diné (Navajo) Hózhó wellness philosophy, along with nursing research and theory, informed the development of a theoretical nursing model, the Hózhó Resilience Model that can be used to generate patient-centered nursing knowledge through connections among our theories, research, and practice. The Hózhó Resilience Model is a model that can be used to understand American Indian worldviews in relation to health, and may also be used to guide future research and nursing practice with the American Indian population.

Culturally Safe Mentoring for American Indian Nursing Students.

Being the least-represented ethnic/racial group in college settings, American Indian students may experience loneliness and self-doubt related to the challenges of adapting to an environment that embodies values, norms, and culture so different from those represented in their traditional culture. Ongoing health disparities and psychosocial inequities, and persisting impacts of historical colonization, have led to additional hardships for these students that further complicate their academic experiences. Fostering culturally safe learning environments where compassionate and caring faculty provide culturally aligned teaching is important in addressing these complex disparities. Derived from American Indian values and teachings, we present a culturally safe intergenerational mentoring approach that emphasizes the nursing mentors' responsibility to support the growth and success of American Indian nursing students. This approach, drawn from the wisdom of American Indian teachings, focuses on students' strengths and culturally based protective factors. Culturally informed faculty who are aware of the historical impacts of colonization and who have adequate mentoring capacity (time, interest, and commitment) contribute to safe and effective learning environments. Culturally safe mentoring is one approach to promoting American Indian students' potential for academic and professional success.

Diné (Navajo) Traditional Knowledge Holders' Perspective of COVID-19.

From the start of the COVID-19 pandemic on the Navajo Nation, Diné (Navajo) traditional knowledge holders (TKHs), such as medicine men and women and traditional practitioners, contributed their services and healing practices. Although TKHs are not always fully acknowledged in the western health care system, they have an established role to protect and promote the health of Diné people. To date, their roles in mitigating the COVID-19 pandemic have not been fully explored. The purpose of this research was to understand the social and cultural contexts of the COVID-19 pandemic and vaccines based on the roles and perspectives of Diné TKHs. A multi-investigator consensus analysis was conducted by six American Indian researchers using interviews with TKHs collected between December 2021-January 2022. The Hózhó Resilience Model was used as a framework to analyze the data using four parent themes: COVID-19, harmony and relationships, spirituality, and respect for self and discipline. These parent themes were further organized into promoters and/or barriers for 12 sub-themes that emerged from the data, such as traditional knowledge, Diné identity, and vaccine. Overall, the analysis showed key factors that could be applied in pandemic planning and public health mitigation efforts based on the cultural perspective of TKHs.

A mixed-methods study protocol on factors contributing to suicide clusters among Native American youth in a northern plains reservation.

Introduction: Suicide and suicide clusters within Native American Reservation communities are devastating to the entire community and increase individuals' risk for suicide over the lifespan. The objective of this paper is to describe the Indigenous community-based participatory research protocol implemented in partnership with the Fort Belknap Indian Community in Montana, United States. The study protocol was developed to understand suicide risk and protective factors, and community-derived solutions, in a reservation community with history of a suicide cluster and high rates of youth suicide. Methods: In this mixed-methods study, qualitative data from youth, adults, and service providers and quantitative data from 200 adolescents and young adults (aged 14-24 years) were collected in Fort Belknap, Montana from May - December of 2022. Qualitative data were collected first via in-depth interviews and focus groups. Survey questions included validated and pre-tested measures of factors youth experience across socio-ecological levels. Thematic analysis was applied to the qualitative data; and logistic regression models were used to examine relationships within the quantitative data. Discussion: This study will add a multi-dimensional perspective to our current understanding of (1) risk and protective factors for suicide, community-derived postvention solutions, and insights on community assets, and (2) the current health and psychosocial status of youth in the Fort Belknap community. This study may serve as an exemplar of co-created, culturally safe solutions designed to address mental health resource gaps. Next steps include development of a suicide crisis response tool kit and a culturally aligned postvention intervention that will enhance individual, family, and community survivance.

Development of an American Indian Diabetes Education Cultural Supplement: A Qualitative Approach.

OBJECTIVE: The purpose of this study was to culturally enhance a diabetes education program for Diné (Navajo) community members with Type 2 diabetes. Though the recommendation to culturally adapt health education curricula was meant to improve health education for American Indians and Alaskan Natives (AIANs), it has inadvertently created a "one size fits all" approach. This approach does not properly address the need for tribe-specific cultural health messaging, defined as incorporating cultural elements deemed relevant to the population. Tribe-specific health information and programming, such as integrating Diné worldviews and Indigenous knowledge among Diné people as described here, are essential to creating a culturally relevant and effective and meaningful approach to disease self-management. METHODS: A conversation guide, based on the Hózhó Resilience Model-a Diné framework on healthy living, was used to engage key cultural experts in interviews about traditional stories and teachings regarding health and wellness. Three specific self-care behaviors relevant to Type 2 diabetes self-management were discussed: (1) healthy eating, (2) physical activity, and (3) healthy coping. Interviews were audio-recorded, transcribed and analyzed using a qualitative thematic analysis method. RESULTS: Diné healers and cultural experts informed the development of an educational tool called Diné Health. Key themes that emerged from the data included the importance of discipline, positivity and mindfulness in the context of Hózhó. CONCLUSION: Culturally safe and meaningful engagement with cultural leaders and the use of qualitative research methods can inform deep-level cultural adaptations essential to developing tribe-specific diabetes education programs. The approaches used here can guide the development, implementation, and testing of culturally-informed health education for AIAN populations.

Diné (Navajo) Female Perspectives on Mother-Daughter Cultural Assets Around the Transition to Womanhood: A Qualitative Study.

INTRODUCTION: American Indian (AI) people have protective factors embedded in cultural teachings that buffer against high-risk behaviors. This study applies a qualitative, grounded theory approach to identify cultural assets for a Diné (Navajo) mother-daughter intervention aimed at preventing substance abuse and teen pregnancy. METHOD: Focus groups and in-depth interviews were conducted with 28 AI females' ages 8 years and older from the Navajo Nation. RESULTS: Key themes were (a) preserving the Diné way of life, (b) cultural assets related to being a healthy Diné woman, (c) matrilineal networks as a source of strength/pride, (d) historical trauma as a source of resilience, (e) male influences as protective health factors, (f) Western education as a measure of success, and (g) integrating different belief systems. DISCUSSION: Study findings may be applied as foundational elements for culturally grounded AI substance abuse and teen pregnancy prevention strategies, as well as culturally safe nursing practice.

The Generational Impact Of Racism On Health: Voices From American Indian Communities.

Structural racism toward American Indians and Alaska Natives is found in nearly every policy regarding and action taken toward that population since non-Natives made first contact with the Indigenous peoples of the United States. Generations of American Indians and Alaska Natives have suffered from policies that called for their genocide as well as policies intended to acculturate and dominate them-such as the sentiment from Richard Henry Pratt to "kill the Indian…, save the man." The intergenerational effect is one that has left American Indians and Alaska Natives at the margins of health and the health care system. The effect is devastating psychologically, eroding a value system that is based on community and the sanctity of all creation. Using stories we collected from American Indian people who have experienced the results of racist policies, we describe historical trauma and its links to the health of American Indians and Alaska Natives. We develop two case studies around these stories, including one from a member of the Navajo Nation's experiences during the COVID-19 pandemic, to illustrate biases in institutionalized structures. Finally, we describe how the American Indian and Alaska Native Cultural Wisdom Declaration can help policy makers eliminate the effect of systemic racism on the health of American Indians and Alaska Natives-for instance, by lifting constraints on federal funding for American Indian and Alaska Native initiatives and allowing payment to traditional healers for their health services.

The Diné (Navajo) Hózhó Lifeway: A Focused Ethnography on Intergenerational Understanding of American Indian Cultural Wisdom.

Purpose: Hózhó is the cultural wisdom that guides the Diné lifeway. This study examines understanding of cultural wisdom (CW) across three generations: elders, adults, and adolescents. Method: A focused ethnography was conducted on the Navajo Nation. Twenty-two Diné (Navajo) were recruited through convenience sampling. Data were collected via two semistructured interviews and photovoice methods. Data were analyzed using content analysis, thematic analysis, and participatory visual analysis of photos. Results: The Diné elders embodied the greatest in-depth understanding of CW followed by the adolescents. An unexpected finding was the scarcity of understanding of CW among the adults. Conclusion: The Diné understanding of CW is transferred through discussion with elders, listening to and speaking traditional language, cultural preservation activities, and participation in cultural practices. The Diné believe cultural wisdom is a health sustaining protective factor, therefore strategies to restore, promote, and support the intergenerational transfer of cultural wisdom remains a tribal priority.

How Should Allopathic Physicians Respond to Native American Patients Hesitant About Allopathic Medicine?

American Indian (AI) and Indigenous peoples utilize traditional medicine/healing (TM/H) for health and well-being. Allopathic health care practitioners (HCPs) receive minimal training and education on TM/H and its application and integration into health care settings. Lack of knowledge and practice guidelines on how to navigate these 2 health care perspectives (allopathic and traditional) creates uncertainties in the treatment of AI and Indigenous peoples. Such conflicts can undermine patient autonomy and result in culturally incongruent practice. This article presents a case study showcasing suggestions for how HCPs can direct clinical decision making when working with AI/Indigenous patients who utilize TM/H. The article argues that health professions education institutions and HCPs must dedicate effort to expanding awareness of and education about TM/H to enhance the delivery of evidence-based and integrated clinical treatment for AI/Indigenous patients.

Concept analysis of Diné Hózhó: a Diné wellness philosophy.

American Indian Alaska Native people of the United States face challenges in attaining physical, mental, spiritual, and environmental health. This article presents a concept analysis of Diné Hózhó, a complex and misunderstood wellness concept the Diné (Navajo) strive to attain. Findings from a literature review are presented to explore anthropological definitions and uses of the concept Hózhó. The method of concept analysis of Walker and Avant is utilized, model cases are presented. Recommendations for application in nursing practice are presented.