Cultural Competence in Nursing: Lessons from a Native American Powwow

Introduction

Diversity is a word that perhaps means something different to each and every individual (Campinha-Bacote, 2003). What is certain, however, is that the changing demographics of the modern-day multicultural world have, and continue to, challenge healthcare professionals to consider cultural diversity as a fundamental concern in the health sector. The U.S. population is projected to reach 400 million by 2050, and estimates show that by then, no single ethnic group will constitute a majority of the country as a whole (Cooper, 2012). These statistics present a vivid picture of the importance of cultural competence and sensitivity among stakeholders in key sectors of the economy, including the health sector.

To deliver quality care to people from diverse backgrounds, healthcare professionals will need to understand the values, beliefs, customs, and practices associated with different cultures, and how these relate to the delivery and provision of care. This is the first step towards delivering culturally competent care in a rapidly evolving environment (Campinha-Bacote, 2003). This drive for cultural competence was the motivating factor behind my decision to attend the August edition of the Native American powwow ceremony in Arlee, Montana. The experience increased my awareness of the Native American culture and changed my worldview about diversity and Aboriginal communities. The subsequent sections of this paper describe the powwow ceremony and the cultural lessons learned as an individual and as a prospective caring nurse generalist.

Native American powwows are gatherings where Native Americans come together to sing and dance, meet up with old friends, and make new ones. The main aim of the event is to renew the culture of Native Americans and preserve American Indians' rich heritage. Sources offer different accounts of how the powwow began. Some believe that when Native American tribes were forced onto reservations, the government granted them the authority to hold cultural dances that the public could attend. Other sources, however, suggest that the powwow originated from the war dance societies of the Southern Plain Tribes, such as the Ponca.

Description of the Cultural Event

At a powwow, people from various Native American tribes sing, dance, and share their songs, which range from religious and social to war songs. Main activities include singing and dancing contests, feasting, encampments, powwow princess contests, parades, softball tournaments, horse races, and hand games (McCluskey, 2009). The scheduled activities differ from powwow to powwow, depending on the type and location (McCluskey, 2009).

At the Arlee Powwow, dancing is the primary activity. The event begins with the Grand Entry (McCluskey, 2009). In the Grand Entry, the eagle staff is carried into the circle, accompanied by the American, Canadian, state, and tribal flags (McCluskey, 2009). Title holders from tribal pageants then make their way into the circle together with other invited dignitaries. The male dancers registered to take part in the ceremony follow the dignitaries, beginning with the traditional dancers, the grass dancers, and finally the fancy dancers. The women follow in the same order as the men, and then the little boys' and girls' traditional and fancy dancers make their way into the arena (McCluskey, 2009).

The dancers dance clockwise around the arbor, showcasing their outfits and dance steps and giving the audience a sense of what to expect in the main event (McCluskey, 2009). The dancers' attire is authentic, consisting of a headdress, apron, moccasins, and rattles or bells (McCluskey, 2009). The term "outfit" is used in place of "costume," as the latter is considered derogatory (McCluskey, 2009). All dancers are required to register for prize money and to take part in the Grand Entry.

The Grand Entry lasts about half an hour, after which a flag song — the equivalent of a national anthem — is sung to mark the start of the ceremony. An invocation is said to bless the gathering, and the eagle staff, which is always positioned above the American flag, is brought to the announcer's stand. The positioning of the eagle staff above the American flag signifies the first nation. The announcer then extends a welcome to attendees, followed by brief speeches from selected dignitaries (McCluskey, 2009). Once this portion of the event is completed, the dancing begins.

The dancing begins with the men's traditional dance — a dance tracing its roots to times when hunters would return to the village and dance out their story of tracking prey or an enemy, or when war parties would recount their experiences upon returning from battle (McCluskey, 2009). Traditional dancers' outfits are decorated with quillwork and beadwork and are often more subdued in color than those of other dancers (McCluskey, 2009). These dancers usually wear a circular bustle of eagle feathers around their waists, signifying unity and continuity (McCluskey, 2009). They often carry honor staffs, weapons, and shields to signify their status as warriors (McCluskey, 2009). The traditional dance competition is divided into five age groups: little boys (nine and under), junior boys, teens, men, and 50-plus (McCluskey, 2009). Dancers are judged on how well they follow the beat of the drum, how well they keep to the music, and whether they stop when the music does, with both feet on the ground (McCluskey, 2009).

The men's fancy dance follows, building on the traditional dance with fancy footwork, varied body movements, acrobatic steps and motions, and increased speed (McCluskey, 2009). This is a freestyle kind of dance in which dancers are allowed to do anything to keep up with the music (McCluskey, 2009). It is danced mostly by young men and boys and is divided into four categories: little boys, junior boys, teen boys, and men (McCluskey, 2009). Fancy dancers, like their traditional counterparts, are expected to follow the beats of the drum and have both feet on the ground when the music stops.

The grass dance is the last dance in the men's competition (McCluskey, 2009). It was borrowed from the Omaha tribe, with the dancers' outfits — including the eagle-bone whistle, the crow belt, and the hair roach — mostly representing the emblems of the Omaha society (McCluskey, 2009). The grass dance step involves tapping the ball of one foot on one beat, placing it down flatly on the next, and then repeating the action on the opposite foot without missing a beat (McCluskey, 2009). Dancers are required to keep their heads moving up and down with the beat of the drum (McCluskey, 2009). Like all other dancers, they must follow the drumbeats and stop with both feet on the ground (McCluskey, 2009). This competition is divided into four categories: little boys, junior boys, teen boys, and men (McCluskey, 2009).

The men's dances are followed by the women's traditional dance (McCluskey, 2009). Traditional female dancers' outfits are mostly decorated with shells, elk's teeth, and ribbonwork, and typically include necklaces, chokers, earrings, hair ties, concho belts, knee-high leggings, and moccasins (McCluskey, 2009). The dancers mostly carry feathers, and the dance involves remaining stationary and bending the knees up and down slightly (McCluskey, 2009). The calmness inherent in the dance is symbolic of the times when women waited patiently for their husbands to return from war (McCluskey, 2009). The rules are similar to those governing the men's competitions (McCluskey, 2009), and the traditional women dancers are categorized into four groups: little girls, junior girls, women, and 40-plus (McCluskey, 2009).

Immediately following the traditional dance is the fancy shawl dance — a newer addition to the competition (McCluskey, 2009). The outfit in this case consists of a decorated knee-length cloth dress, a fancy shawl, beaded moccasins with matching leggings, and various pieces of jewelry (McCluskey, 2009). The dance is significantly similar to the men's fancy dance, with the style moving toward spinning and increased movement (McCluskey, 2009). The competition is divided into three categories: women, junior girls, and little girls, with the same rules as the men's competitions (McCluskey, 2009).

The final dance in the competition segment is the jingle dress dance, associated most closely with the Ojibway community (McCluskey, 2009). The outfits are made from cloth covered with hundreds of jingles or metal cones (McCluskey, 2009). The competition is categorized into two groups: junior girls and women, with the same rules as those governing the male dancers — keeping in line with the music and stopping when it does, with both feet on the ground (McCluskey, 2009).

As the judges deliberate and cast their ballots to determine the winning teams, the audience is given an opportunity to take to the floor and exhibit their dancing styles in categories such as the owl dance (for couples), the friendship dance, and the crow hop dance (McCluskey, 2009). Spectators are allowed to offer money and gifts to the most impressive dancers (McCluskey, 2009). Finally, there is the intertribal dance, where everyone is welcome to take part — including tourists dancing in their own style. The intertribal dance symbolizes the Native American community's appreciation for diversity and visitors (McCluskey, 2009). The songs played during the intertribal dance are mainly geared toward honoring veterans. In the Native American culture, the good of all outweighs the good of the individual, and the best death a man could have was to fall defending his tribesmen (McCluskey, 2009). Songs honoring the fighting men who went to war to defend their tribe are therefore a crucial element of powwow celebrations (McCluskey, 2009).

After the intertribal dance, the judges announce the winners in the various dance categories, who are crowned by selected dignitaries. The event organizers then thank the participants and attendees, a closing prayer is offered, and a veteran takes the Eagle Staff down and leads the Grand Exit (McCluskey, 2009).

Lessons for Self and Other Caring Nurse Generalists

A number of miscellaneous activities extending into the night follow the closing ceremony. These include: (i) hand games (stick games); (ii) the 49er, where dancers come together to sing and share stories; (iii) the powwow princess contest, where young girls compete for the princess designation and are judged on their poise, communication skills, cultural knowledge, and customs; and (iv) parades and rodeos, which offer a chance for cowboys from across the Native American world to showcase their honored persons, animals, regalia, and outfits (McCluskey, 2009).

The powwow festival serves as the community's way of expressing itself and articulating its cultural heritage. I was personally able to learn a number of crucial aspects about Native American culture from the event. The first lesson is that the Native American culture values procedure and organization. The Grand Entry and Exit at the powwow ceremony demonstrate that the community values order and procedure. The scheduled event follows a set procedure by which all participants and spectators abide. The same kind of order and respect for procedure ought to be demonstrated in the health sector. The essence of nursing is to conduct oneself in line with the policies and procedures governing the profession at all times. This helps ensure that the nurse practices according to agency rules and is able to deliver trans-cultural care to diverse patients by choosing the best and most culturally congruent way to perform a task (Squires, Moralejo, & LeFort, 2007).

A second element learned from the powwow is that the Native American culture values ethics and morals. Attendees are not allowed to use drugs or alcohol on the powwow grounds (McCluskey, 2009), and they are expected to dress appropriately and adorn the correct outfits for their particular competitions (McCluskey, 2009). Respect for authority is demonstrated by the expectation that attendees will not boo the judges and will stand as the flag song and other honor songs are sung (McCluskey, 2009). Standards exist to govern ethical conduct during the powwow proceedings, and participants and attendees have a responsibility to adhere to them. Attendees are required to coordinate with the master of ceremonies, head singers, or the arena director whenever they are unsure about the appropriateness of an action, ensuring that conduct remains within the ethical guidelines governing the event at all times.

In the same way, nurses ought to be guided by ethics in both their personal lives and professional practice. They are expected to adhere to the codes of conduct governing their profession when faced with ethical dilemmas. Consultations with superiors and colleagues are crucial to ensuring one conducts themselves in the most ethical manner in the workplace. Just as the powwow dancers are the face of their community and symbolic representatives of its heritage, the nurse is the face of the nursing profession. As such, nurses are obligated to conduct themselves in a manner that upholds the profession's ethical standing at all times.

Respect for authority is also crucial for practicing nurses in the general care setting. The Native American culture, as evident from the powwow celebrations, demonstrates the importance of respecting authority in the workplace. Despite the constant struggles between Native American communities and the federal government, the former still recognizes the latter's authority — evident from the inclusion of the American flag — and shows respect for it (Grandbois, Warne, & Eschiti, 2012). In the same way, as a nurse I am obliged to accept the clinical authority of medical professionals over the nursing profession (Raeve, 2002). As an upcoming nurse, I recognize the need to work collaboratively with medical professionals to deliver the best-quality trans-cultural care to Native American patients.

The prohibition of alcohol and drug use is designed to ensure that peace is not disrupted during powwow celebrations. This portrays the Native American culture as one focused not only on morals but on peaceful coexistence as well. This ideology runs contrary to the common misconception that Native American communities are lovers of war. It teaches that, as a nurse, one way to deliver effective trans-cultural care is by avoiding prejudice. If I am able to avoid prejudice in my professional practice, I will be able to effectively and adequately address the health needs of clients from diverse cultural backgrounds.

Another crucial element of the Native American culture is its focus on utilitarianism — the good of all above the good of the individual. As discussed, Native Americans advocate for the spirit of compromising for the sake of the greater good (McCluskey, 2009). Veterans are honored during powwow celebrations because it is believed that the best death a man could have is to fall defending his tribesmen (McCluskey, 2009).

Nurses would be more effective in delivering trans-cultural care to Native American patients if they demonstrated sensitivity to this aspect of Native American culture. The principle of selecting the option that creates the most happiness for the most people ought to guide the formulation of public health policies targeting Aboriginal communities. Moreover, in primary care settings, nurses could maximize Aboriginal patients' health outcomes by grounding their end-of-life advice in the principle of utilitarianism. This is one way through which caring nurse generalists in primary care settings can demonstrate cultural sensitivity toward Native American patients.

Activities in the powwow calendar keep evolving as the environment changes and new traditions develop. Fancy dances, for instance, were not part of traditional powwow settings; however, modernization and the adoption of Western culture have made their inclusion relevant (McCluskey, 2009). This introduces the concept of flexibility in one's personal and professional life. There is a need to evolve as the world or environment changes, in order to remain relevant in one's particular sphere. In the nursing context, flexibility is demonstrated through continuous learning — nurses have a responsibility to learn from their peers and from relevant resources to ensure that they remain relevant amid changing demographics in the healthcare setting. Participating in cultural events such as powwows is a form of learning through which nurse practitioners can expand their understanding of other cultures, including their values, beliefs, and practices, and how these influence the provision of care. Interacting with colleagues from diverse cultures and engaging with professional literature on different cultures are additional forms of learning that professional nurses could adopt. Continuous learning is one way through which nurses can ensure that they remain culturally competent and empowered to deliver the best-quality care to a diverse client base.

Conclusion

The modern-day nurse operates in a culturally diverse environment that is constantly evolving. The only way to remain culturally relevant and congruent is by collaborating with people from diverse cultures and engaging in continuous learning to understand the values and beliefs of people from different cultural backgrounds, and how these influence the provision of care. In so doing, nurses are able to change their worldviews and become more appreciative of other cultures, ultimately delivering more compassionate and effective patient care.