Can someone explain this?

[aerorunner80, ADN, BSN, MSN, APRN]

I've seen this several times with elderly native americans in my region (we have mostly navajo). You go in to try to talk to the pt to tell them that they need to be turned or to be put in a chair and their response is to just stare right through you and not say a word. They will hole up and only respond to their family (who is usually with them at all times) using the navajo language. I've see it to the level that they (the pt) won't even respond to the doctor even when the pt speaks and understands english.

It usually starts off that the pt will respond and then for some reason they decide to hole up. They don't refuse or OK anything, they just lay there and do nothing even when they are fully capable.

It is just aggravating sometimes.

Thanks

[sirI, MSN, APRN, NP]

I am not Navajo, but can probably address some of your concerns, aerorunner80.

NAI are a very solitary people and do not normally reach out to outside medical influences. At least, not in my tribal clan. Some do embrace Western medicine, but those are the ones who don't normally adhere to and/or uphold NAI beliefs anymore. We expect silence between the care giver and the patient as well. This is something that I have seen the caregiver have difficulty with for the caregiver is impatient and expects immediate answers to questions.

Questions should be adapted to age and/or cultural level. It is important for the nurse to slow down when communicating with Indian, especially during initial encounters, and when explanations of treatments/medications/health care decisions are being given. Questions should be carefully framed to convey the message of caring. (And, the nurse should not indicate idle curiosity about the culture or cultural practices.)

To address the lack of verbal response: American Indian languages have some of the longest pause times compared to other languages, and especially English. We frequently complain that English speakers “talk too fast.” Silence is valued and long periods of silence between speakers are common. Interruption of the person who is speaking is considered extremely rude, especially if that person is an elder. One will probably not receive a verbal response in this instance.

Other things to consider:

a) Physical distance of several feet is a usual comfort zone

b) Eye contact is not direct or only briefly direct; gaze may be directed over the shoulder

c) Emotional expressiveness may be controlled, except for humor

d) Body movements are minimal

e) Touch is usually not acceptable except a handshake

Hope this helps a little to enable you to understand Indian a little better.

Respectfully,

sirI

[Thunderwolf, MSN, RN]

From SirI

To address the lack of verbal response: American Indian languages have some of the longest pause times compared to other languages, and especially English.

I need to really emphasize this too. Listening is valued as an active skill, with long silence and pauses being used for a couple reasons: one, a sign of outward respect for the speaker (for maybe the speaker has more to say or needs more time to say it); two, again out of respect for the speaker, to listen in a way to collect one's thoughts about the matter in order to answer/respond in an intelligent manner; three, a way of agreeing (what else is there really to say, so the listener says nothing) or a way of disagreeing (without a confrontation....for open disagreement may be seen as a sign of disrespect). For the non Indian speaker wishing immediate feedback, communication may be seen as laborous or difficult. So, how does one know that the message was heard by an Indian listener? If there is behavioral change later, an agreement with the message was reached. If there are remaining questions, you may have to open the door first by leaving the door open for later questions or to structure for a later time to answer any remaining questions....but definately giving ample time "to think about it" first. The American culture at large expects instant communication, back and forth....and the slowing down of the process may be seen as an act of passive aggressive disagreement or respectful disinterest. But for the Indian, the reverse can often be true. Expecting instant answers or responses may demonstrate the lack of listening (an act of uncaring)....which is disrespectful. So, it pays off to go slow: stop and think, speak what one has to say or convey, now let the other digest it, then provide the opportunity later if needed for feedback/questions. Lastly, if one communicates with obvious intention to just "go thru the motions" or "to just rush thru it" so as to instruct or educate without any personal investment on your part....your words may become just wasted words. Many Indian have become "intuned" to and/or may "tune out" what may be perceived as "meaningess words" or "meaningless promises" and "meaningless actions". So, does the issue of trust ring a bell here? Yes, it does. So, if one's words are to be found trustworthy later and to be held meaningful (for education later)....do not promise things now which you cannot or will not deliver (like "I'll be back in 2 minutes" or "I'll bring this for you" and don't). Just as there are cultural barriers and misperceptions about "things Indian" amid the White culture....there are also cultural barriers and misperceptions about "White medicine" amid the Indian culture. The thing here is to be sensitive to the misperceptions "on both sides" and not adding to them. The best thing I can end saying here (which actually sums things up nicely) is....things just take time. So in reference to nursing, discharge teaching really needs to begin on the day of admission....not on the last day. It conveys personal interest and investment (trust building), and it also provides opportunity to digest the message (meaningful).

[Medicine Eagle]

Okay, now I am concerned about how this will affect my ability to provide emergent medical care in the ER. When it is posible I always take time to sit and talk to my pts. and their family. I never lie to my pts. or mke promises that I can not keep. However, when it comes to an MI or something like that, there are times when immediate responses to questions is crucial. The last thing I would ever want to do is inadvertenly be rude or disrespectful. Any ideas? Is there a way to obtain this info. quickly when required without being disrespectful?

Tired Brave Heart

[Thunderwolf, MSN, RN]

I sense your angst. In emergency situations, one must focus on the immediate emergency. However, if it is possible to have family there, they may often be the best source of patient information and can assist in instruction. Ask who "does the patient view" as his/her spokesperson when he/she is unable/unwilling to answer/assist?....and is that person here?....or can that person be reached? In Indian Country, some tribes are more "paternal" in nature, where another may be more "maternal". For example, for an elderly native man....his son may be the spokesperson for him....in a different tribe, it could be his daughter. So, if there are known tribes in your area....get a sense of this for your area. But, in an emergency, one must deal with the emergency in front of you first. If family is there, enlist the help. In an emergency, "state it plainly" that time is brief due to the nature of the emergency....but, soon, there will be plenty of time provided to discuss things more thouroughly....and to ask and answer any questions. I am sure that you are doing fine.