Nursing proc?ss is th? syst?matic m?thod of conducting nursing practic? activiti?s to achi?v? nursing car? obj?ctiv?s. Th? four phas?s ar? 1. ass?ssm?nt, 2. planning, 3. impl?m?ntation, and 4. ?valuation. ?ach phas? includ?s focus?d activiti?s, with att?ntion to cultural issu?s.
During th? ass?ssm?nt phas?, cli?nt information is coll?ct?d and analyz?d. Nursing diagnos?s ar? us?d to guid? nursing activiti?s during lat?r phas?s. How?v?r, ass?ssm?nt activiti?s continu? during subs?qu?nt phas?s to p?rmit r?appraisal of th? cli?nt situation in light of n?w and changing information. Ass?ssm?nt is a nursing r?sponsibility for all individual, group, or community cli?nts.
Culturally sp?cific activiti?s in nursing practic? b?gin during th? ass?ssm?nt phas? and ar? incorporat?d into subs?qu?nt phas?s of th? nursing proc?ss. Th? importanc? of a culturological ass?ssm?nt was first str?ss?d in nursing by L?ining?r (1978) as “a syst?matic appraisal of individuals, groups, and communiti?s as to th?ir cultural b?li?fs, valu?s, and practic?s to d?t?rmin? ?xplicit nursing n??ds and int?rv?ntion practic?s within th? cultural cont?xt of th? p?opl? b?ing ?valuat?d” (p. 85). Such d?finition ?nabl?s nurs?s to conduct culturological or cultural ass?ssm?nts in any s?tting and with all cli?nt populations. This pap?r, by r?f?rring to a numb?r of articl?s and sourc?s discussing valu? syst?m and b?li?fs of Am?rican Indians, r?ports th? r?sults of th? culturological ass?ssm?nt of this group, focusing on historical, cultural, and social practic?s that play th? major rol? in v?rifying sp?cific nursing n??ds of Nativ? Am?ricans.
Structuring an ass?ssm?nt instrum?nt to b? culturally sp?cific ?xpands its us?fuln?ss b?caus? of th? broad scop? of cultural data that may hav? r?l?vanc? for ass?ssm?nt. L?ining?r (1978) outlin?d nin? major domains that provid? cultur?-sp?cific information for a culturological ass?ssm?nt. Th?s? includ? 1. lif? patt?rns/lif?styl?, 2. valu?s and norms, 3. myths and taboos, 4. worldvi?ws, 5. div?rsity, similarity, and variations, 6. lif? caring rituals and rit?s of passag?, 7. folk and prof?ssional h?alth and illn?ss syst?ms, 8. caring b?haviors, and 9. chang? and acculturation. Within th?s? broad domains th? nurs? structur?s qu?stions to obtain a culturally sp?cific ass?ssm?nt of th? cli?nt. Wh?n combin?d with th? physical, psychological, and spiritual ass?ssm?nts, a compr?h?nsiv? plan of car? can th?n b? consid?r?d.
Cor? factors must b? consid?r?d wh?n d?v?loping a cultural ass?ssm?nt instrum?nt. Cat?gori?s includ?d in th? “Guid? for th? Ass?ssm?nt of Cultural Manif?stations” provid? a fram?work to incorporat? qu?stions for an inclusiv? cultural ass?ssm?nt (H?rb?rg 2001). Th? outlin? is bas?d on commonaliti?s that ?xist b?tw??n cultur?s. What b?com?s ?vid?nt through th? ass?ssm?nt proc?ss is how traits ar? manif?st?d within a sp?cific cultur?.
For th? ?ld?rly, th? int?rr?lat?dn?ss b?tw??n physical condition and ?motional symptoms n?c?ssitat?s a compr?h?nsiv? nursing ass?ssm?nt. On? instrum?nt that provid?s compr?h?nsiv? ass?ssm?nt data for nurs?s who ar? working with ?ld?rly cli?nts with m?ntal h?alth probl?ms is th? Psychog?riatric Nursing Ass?ssm?nt Protocol (Thompson-H?ist?rman, Smull?n, and Abraham 2000). Oth?r psychosocial ass?ssm?nts for gath?ring information about th? m?ntal h?alth n??ds of ?ld?rly cli?nts ar? d?scrib?d by M. A. Browning (1989).
By including th? cultural p?rsp?ctiv? with biological/physiological, sociological, psychological, and spiritual p?rsp?ctiv?s, th? nurs? has a compr?h?nsiv? ass?ssm?nt fram?work. Th? d?pth of th? ass?ssm?nt d?p?nds upon th? quality of th? nursing ass?ssm?nt instrum?nt and scop? of information that is n??d?d to d?v?lop a r?alistic plan of car?.
Birth and f?rtility ratios of Am?
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rican Indian population
In t?rms of p?rc?ntag?s and proportions, analysis comparing Am?rican Indians with all rac?s in th? Unit?d Stat?s profil? a d?mographic transition for Am?rican Indian populations (Hamburg ?t al. 1999). Th? Am?rican Indian population “pyramid has a slightly ind?nt?d bas? in th? und?r-10 ag? group, signaling a d?clin? in f?rtility during th? 1970s” (Si?v?rs and Fish?r 2000, p. 23). G?n?rally, th? 19-and-und?r group forms a broad portrait, contrasting with th? sharply ind?nt?d bas? of th? U.S. total population. This bas? shows a significant d?cr?as? in f?rtility ov?r th? last two d?cad?s. Th?s? contrasting bas?s hav? important implications for d?p?nd?ncy ratios. Th? mod?l of d?mographic transition provid?s thr?? major stag?s:
1. High f?rtility and high mortality
2. High f?rtility and d?clining mortality
3. D?clining f?rtility and d?clining mortality (Hamburg ?t al. 1999).
Although th? Am?rican Indian population has d?clin?d by n?arly 20 p?rc?nt during th? last two d?cad?s, its growth rat? r?mains almost twic? that of th? U.S. total population. In t?rms of mortality, th?r? has b??n a pr?cipitous d?clin? in Am?rican Indian infant and mat?rnal mortality during th? last thr?? d?cad?s. Most of this d?clin? can b? attribut?d to improv?d sanitation (d?cr?asing th? pot?ntial for inf?ction) and th? ?xpanding r?sourc?s and s?rvic? d?liv?ry of th? IHS. Int?r?stingly, Am?rican Indian infant mortality, ?xc?pt for Alaska Nativ?s, is som?what high?r than th? U.S. total rat? but significantly low?r (by 30 p?rc?nt) than black infant mortality. Blacks also ?xp?ri?nc? almost twic? th? mat?rnal mortality of Am?rican Indian populations (Joos and ?wart 1988).
Proportionat?ly, th? top for th? Am?rican Indian population pyramid is much narrow?r than th? top of th? pyramid for U.S. all rac?s. That is, a much larg?r s?gm?nt of th? total U.S. population is 45 y?ars of ag? or old?r. During th? latt?r 1990s, a larg?r proportion (19.7 p?rc?nt) of th? total U.S. population (compar?d with 13 p?rc?nt of th? Am?rican Indian population) has th? pot?ntial of ?nt?ring th? 65+ ag? cat?gory. How?v?r, b?caus? th? numb?r of Am?rican Indians ov?r 75 is small, th? numb?r that will ?nt?r this cat?gory during th? n?xt two d?cad?s will b? proportionat?ly larg?r. Th? ?xact numb?r is difficult to ?stimat? b?caus? th? U.S. c?nsus, whil? making proj?ctions for whit? and black populations, do?s not do so for Am?rican Indian populations (Schulz and Manson 2000).
Rough ?stimat?s sugg?st as l?ast a doubling of th? Am?rican Indian population ov?r 75 by th? y?ar 2000. Giv?n th? possibility of a crossov?r ?ff?ct, in which survival rat?s incr?as? for Am?rican Indians ov?r 65, th?s? proj?ctions may b? s?v?r? und?r?stimat?s. Additional analysis in this ar?a is critical for ?stimating futur? h?alth and m?ntal h?alth s?rvic? n??ds.
Incom? and ?conomic matt?rs of Am?rican Indians
Th?r? is no r?gion of th? Unit?d Stat?s wh?r? Am?rican Indians ov?r ag? 65 hav? av?rag? p?r capita incom?s ?qual to thos? of whit?s. On th? av?rag?, whit?s hav? 40-59 p?rc?nt mor? p?r capita incom? r?gardl?ss of wh?th?r th?y liv? in urban or rural ?nvironm?nts. Within th? Am?rican Indian population, ?xc?pt for th? North?ast, which has n?arly comparabl? p?r capita incom?, urban Indians do much b?tt?r than rural Indians. Throughout rural Am?rica, ?ld?rly Am?rican Indians hav? 70 p?rc?nt or l?ss of th? p?r capita incom? of th?ir urban Indian count?rparts (Si?v?rs and Fish?r 2000).
In th? W?st, rural Indian populations in Arizona and N?w M?xico hav? twic? th? numb?r of p?rsons b?low th? pov?rty lin? compar?d with urban populations, ?sp?cially in urban California.
Whil? whit? populations 65 and ov?r hav? about on? in fiv? p?rsons b?low or slightly abov? th?
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pov?rty lin? (25 p?rc?nt abov?), comparabl? ratios for Am?rican Indian populations rang? from on? in thr?? to on? in two. In rural ar?as of th? Unit?d Stat?s, n?arly half th? total ?ld?rly Am?rican Indian population liv?s at or b?low th? pov?rty l?v?l. This g?n?ralization holds d?spit? th?r? b?ing no diff?r?nc? b?tw??n whit? and Indian populations 65 and ov?r in ?ith?r urban or rural s?ttings with r?sp?ct to labor forc? participation and ?mploym?nt (Schulz and Manson 2000).
Social n?tworks of Am?rican Indians
Rural ag?d populations, both Indian and whit?, ar? mor? lik?ly to b? living in family ?nvironm?nts, that is, with clos? r?lativ?s, than ar? th?ir urban count?rparts. Similarly, for both populations, th? old?r th? individuals ar?, th? l?ss lik?ly th?y will b? living with famili?s.
About thr??-fourths of rural Am?rican Indians b?tw??n 65 and 74 liv? with th?ir famili?s, whil? only about half th? urban Indian population ov?r th? ag? of 75 liv? within a family ?nvironm?nt. Th? sam? dynamics, with only slightly diff?r?nt p?rc?ntag?s, ?xist for whit? populations. At first glanc?, it s??ms that ?ld?rly Am?rican Indians living in rural ar?as hav? gr?at?r pot?ntial for family support. How?v?r, twic? as many rural Indian famili?s with ag?d m?mb?rs ar? b?low th? pov?rty lin? compar?d with urban Indian famili?s with m?mb?rs ov?r 65. Thus, whil? about two-thirds of rural Am?rican Indians ov?r 75 ar? lik?ly to b? living in a family ?nvironm?nt, mor? than a third of th?m can ?xp?ct to liv? b?low th? pov?rty l?v?l. On th? oth?r hand, whil? 50 p?rc?nt of ?ld?rly urban Am?rican Indians can b? ?xp?ct?d, in a statistical s?ns?, to b? living with famili?s, only 16 p?rc?nt will b? b?low th? pov?rty lin? (Si?v?rs and Fish?r 2000).
Again, similar dynamics work with whit? populations. Th? small?st proportion of ag?d whit?s living b?low th? pov?rty lin? ar? urban whit?s ag?d 65-74, whil? th? high?st proportion is found among rural individuals ag?d 75 and ov?r. Not?, how?v?r, that th?r? ar? n?arly ?qual proportions of Am?rican Indian ?ld?rly living in urban and rural ?nvironm?nts, whil? urban whit? ?ld?rly outnumb?r th?ir rural whit? count?rparts thr?? to on? (Schulz and Manson 2000).
Although statistics for family r?sid?nc? show that ag? and location (urban v?rsus rural) d?t?rmin? family ?nvironm?nt r?gardl?ss of ?thnicity, incom? is strongly associat?d with ?thnicity. R?gardl?ss of ag? or location, Indian famili?s with ?ld?rly m?mb?rs hav? thr?? tim?s th? proportion of th?ir population b?low th? pov?rty lin? as do whit? famili?s. At th? ?xtr?m?s, rural Nativ? Am?ricans ov?r 75 living in famili?s hav? ?ight tim?s (800 p?rc?nt) th? numb?r of individuals b?low th? pov?rty lin? compar?d with urban whit?s b?tw??n 64 and 75 (Joos and ?wart 1988).
G?n?ral conclusions about family support must b? s??n in this cont?xt. In fact, pov?rty may b? on? of th? major d?t?rminants of ?xt?nd?d famili?s. ?ld?rly Indians liv? with th?ir childr?n and grandchildr?n, not only b?caus? of cultural norms but to shar? and r?ciprocat? scarc? and irr?gular r?sourc?s.
Th? proportion of ?ld?rly living in famili?s has b??n analyz?d, ?mphasizing ag? cohorts and urban or rural locations. Th? r?maining individuals not living in a family can b? divid?d into thos? living in hous?holds with non-r?lativ?s and thos? living in group quart?rs. Th? non-r?lativ? r?sid?nc? cat?gory includ?s th? subcat?gory living alon?. Th? cat?gory of group quart?rs includ?s th? subcat?gory ‘inmat? of institution,’ which is furth?r subdivid?d into ‘hom? for th? ag?d’ (National Indian Council on Aging 1981). Importantly, ov?r 95 p?rc?nt of individuals in th? non-r?lativ? cat?gory ar? individuals who liv? alon?. Th? sam? holds tru? for ov?r 90 p?rc?nt of p?rsons classifi?d as inmat?s of institution; th?y ar? actually living in hom?s for th? ag?d.
As might b? ?xp?ct?d, advancing ag? in both Indian and whit? populations incr?as?s th? probability of an individual's living alon? or moving into a hom? for th? ag?d. Roughly a third of th? 75-and-ov?r population, Indian or whit?, rural or urban, liv? alon?; how?v?r, th?r? ar? dramatic diff?r?nc?s b?tw??n urban and rural ar?as in th? proportion of 75-and-ov?r individuals living in hom?s for th? ag?d. D?spit? a gr?at?r proportion of th? total Indian rural population b?ing ov?r 65 (5.8 p?rc?nt) compar?d with urban Indian populations (4.7 p?rc?nt), urban populations us? hom?s for th? ag?d mor? than twic? as oft?n. This may b? th? r?sult of gr?at?r availability of hom?s for th? ag?d in urban ar?as. How?v?r, as mor? rural Indians r?ach ag? 75 with th? incr?as?d probability of d?g?n?rativ? dis?as?s and organic brain syndrom?, many rural Indian famili?s will fac? unpl?asant choic?s. Mor? than lik?ly, n??d?d r?sourc?s will not b? availabl? (National Indian Council on Aging 1981).
Growing old?r pr?s?nts gr?at difficulti?s for a sizabl? s?gm?nt of Am?rica's ag?d population, and b?ing Indian int?nsifi?s th?s? difficulti?s. But b?ing a rural Indian ov?r 75 may m?an b?ing among th? most n?gl?ct?d and vuln?rabl? in Am?rican soci?ty.
High?r proportions of p?opl? und?r ag? 15 and ag? 65 or old?r in rural Indian populations contribut? to high?r d?p?nd?ncy ratios. A d?p?nd?ncy ind?x or ratio is a proportion of thos? individuals und?r 15 plus thos? 65 and ov?r (i.?., thos? th?or?tically d?p?nd?nt), divid?d by th? total population of individuals 16-64, that is, thos? ?ngag?d in wag? labor or production. This ratio of d?p?nd?nts to produc?rs or support?rs is a simpl? m?asur?, h?lpful in calculating a soci?ty's social burd?n (i.?., d?t?rmining r?quir?d p?rsonn?l r?sourc?s to car? for th? young and ?ld?rly) (Hill and Sp?ctor 1971).
D?p?nd?ncy ratios for whit? and Indian urban populations ar? v?ry similar. In contrast, rural Indian ratios ar? much high?r than th? urban ratios and consid?rably high?r than th? ratios for both urban and rural whit? populations. Som? rural Indian populations, such as th? Navajo, hav? d?p?nd?ncy ratios gr?at?r than Third World countri?s such as Chad or Brazil. High f?rtility and d?cr?asing mortality -- th? d?mographic transition -- ar? a major part of th? Navajo's d?p?nd?ncy ind?x.
On? might not? that rural Indian famili?s ar? going to hav? an incr?asingly difficult tim? supporting th?ir d?p?nd?nt m?mb?rs. Rural famili?s with low incom?s simply do not hav? th? r?sourc?s to support infirm ?ld?rly family m?mb?rs. Th? IHS, with d?cr?asing r?sourc?s from constant dollars, do?s not hav? th? funding to m??t th? d?mand of chronic illn?ss in this ag? group.
Physical h?alth of Am?rican Indians
Most r?ports sugg?st that s?v?ral typ?s of physical morbidity -- pn?umonia, diab?t?s, alcoholism, arthritis, and poor d?ntal h?alth -- ar? ?sp?cially d?vastating to old?r Indian populations, with diab?t?s and alcoholism b?ing particularly virul?nt in middl?-ag?d populations. On? study d?t?rmin?d that Am?rican Indians suff?r?d from high?r rat?s of chronic ailm?nts than whit? populations (National Indian Council on Aging 1981). D?spit? th? many limitations of this study, including a 40 p?rc?nt nonr?turn rat? on int?rvi?w?r-conduct?d protocols, its findings ar? sugg?stiv? and consist?nt with th? r?sults of a mor? r?c?nt study among Klamath Indians (Joos and ?wart 1988). Thus, on? in fiv? Indians ov?r ag? 45 (both rural and urban) acknowl?dg?s that poor h?alth int?rf?r?s with daily activiti?s. In th? sam? v?in, th? U.S. c?nsus r?cords that Am?rican Indian populations 65 and ov?r, r?gardl?ss of r?gion or locality (urban or rural), hav? high?r p?rc?ntag?s of disabiliti?s that pr?v?nt th?ir us? of public transportation wh?n compar?d with whit?s.
Cl?arly, physical h?alth probl?ms play a larg? rol? in th? liv?s of old?r Am?rican Indians (Schulz and Manson 2000). An ?stimat?d 73 p?rc?nt of th? ?ld?rly Indian population is mildly to totally impair?d in coping with th? basics of daily living (National Indian Council on Aging 1981). Forty p?rc?nt of all adult Indians hav? som? form of disability (National Indian Council on Aging 1978). Liv?r and gall bladd?r dis?as? also occur mor? oft?n within this population than in any oth?r (Si?v?rs and Fish?r 2000). Oth?r h?alth probl?ms includ? ob?sity, hyp?rt?nsion, and poor vision.
Am?rican Indians’ m?ntal h?alth issu?s
Th? ?ff?ct of poor physical h?alth may assist in ?xplaining th? significantly high?r rat?s of d?pr?ssion among Indian ?ld?rly compar?d with non-Indian ?ld?rly (National Indian Council on Aging 1981; G?n?ral Accounting Offic? 1977). Physical and psychological comorbiditi?s contribut? substantially to th? d?cr?as?d long?vity of this population compar?d with whit?s (Si?v?rs and Fish?r 2000).
In th? 1978 Final Conf?r?nc? R?port on Aging (National Indian Council on Aging 1978), ?. Rhoad?s not?d that th? only m?ntal disord?r cat?gory that aff?ct?d a significant proportion of thos? 60 y?ars or old?r was organic brain syndrom?. Forty p?rc?nt of all visits for this disord?r w?r? by thos? 60 y?ars or old?r. Sinc? this disord?r is oft?n associat?d with d?g?n?rativ? dis?as?s such as art?rioscl?rosis and strok?, this was not surprising. Unfortunat?ly, a cl?ar-cut diagnosis of organic brain disord?r is not ?asily obtain?d; diff?r?ntiating it from aff?ctiv? disord?rs is ?v?n mor? difficult.
In th? g?n?ral ?ld?rly population, ass?ssm?nt and tr?atm?nt of d?pr?ssion includ? id?ntifying possibl? sid? ?ff?cts of m?dication for physical complaints, sid? ?ff?cts of psychotropic and n?urol?ptic m?dications, th? impact of th? individual's p?rsonality on r?porting symptoms or r?sponding to qu?stionnair?s, th? occurr?nc? of r?c?nt traumatic ?v?nts (such as th? loss of a lov?d on?), and th? pati?nt's p?rsonal r?lationships, s?lf-?st??m, and family support. Whil? th?s? ar? also r?l?vant to ass?ssm?nt of d?pr?ssion among old?r Am?rican Indians, languag? and cultural diff?r?nc?s also n??d consid?ration (Hamburg ?t al. 1999).
Most of Am?rican Indians ar? unawar? of appropriat? nursing and social s?rvic?s and do not know how to s??k information about n??d?d car?. Th?y ?xpr?ss conc?rn about what p?opl? might think of th?m if th?y sought such h?lp. Authors r?port that cl?ar urban/rural diff?r?nc?s ?m?rg?d, r?v?aling that old?r Am?rican Indians living in th? city w?r? mor? disadvantag?d than th?ir r?s?rvation count?rparts.
Conclusion
Probl?ms with h?alth and m?ntal h?alth that fac? old?r Am?rican Indians ar? wid?spr?ad and lik?ly to int?nsify if curr?nt tr?nds continu?. S?v?ral publications hav? d?tail?d th?ir ?xc?ss morbidity and mortality and in comparison with whit?s and oth?r ?thnic minoriti?s. Y?t, mor? ?pid?miological surv?ys ar? n??d?d among both rural and urban Indian populations to docum?nt h?alth and m?ntal h?alth n??ds of old?r Am?rican Indians in th? 21-st c?ntury.
R?cognition and und?rstanding of h?alth and m?ntal h?alth probl?ms of old?r Indians hav? b??n slow to matur? in spit? of ?vid?nc? of ?xt?nsiv? n??d. Programs to id?ntify and int?rv?n? among th? ?ld?rly in th? g?n?ral population hav? b??n found to b? ?ff?ctiv?. Y?t, f?w of th?s? hav? found th?ir way to Indian and Nativ? communiti?s. A conc?rt?d ?ffort should b? und?rtak?n to all?viat? th? physical and psychological disabiliti?s that damag? old?r Am?rican Indians, l?ss?n th? burd?n that th?ir illn?ss?s plac? on alr?ady str?ss?d family car?giv?rs, and h?lp local communiti?s in d?v?loping innovativ? r?spons?s to th?s? n??ds.
