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 DOI: 10.1177/1043659605274984

2005 16: 193J Transcult NursRoxanne Struthers, Jana Lauderdale, Lee Anne Nichols, Lillian Tom-Orme and C. June Strickland

Respecting Tribal Traditions in Research and Publications: Voices of Five Native American Nurse Scholars  

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10.1177/1043659605274984JOURNAL OF TRANSCULTURAL NURSING / July 2005Struthers et al. / VOICES OF FIVE NATIVE AMERICAN NURSE SCHOLARS

COMMENTARY

Respecting Tribal Traditions in Research andPublications: Voices of Five Native AmericanNurse Scholars

ROXANNE STRUTHERS, PhD, RNUniversity of Minnesota School of Nursing

JANA LAUDERDALE, PhD, RNFisk–Vanderbilt University School of Nursing

LEE ANNE NICHOLS, PhD, RNThe University of Tulsa School of Nursing

LILLIAN TOM-ORME, PhD, MPH, MS, RN, FAANUniversity of Utah Huntsman Cancer Institute

C. JUNE STRICKLAND, PhD, RNUniversity of Washington School of Nursing

A dialogue with five Native American scholars providesinsight into conducting research and publishing resultingmanuscripts on Native American topics, specifically healingbeliefs and practices. This information provides a means todevelop sensitivity and create understanding about concernsheld by Native Americans regarding sharing certain definedcultural information with those outside the culture. The arti-cle identifies salient tribal issues related to research, dis-cusses perspectives important to tribal nations and Nativeindividuals surrounding research, and supplies a base onwhich to formulate further discussions

Keywords: Native American; American Indian; researchprotocols; publication policies; Cherokee;Comanche; Ojibway; Chippewa; Navaho;Dine’; Anishinaabe

PREFACE

The Journal of Transcultural Nursing is pleased to presenta discussion about the conduct of research and its publicationof the healing beliefs and practices of Native Americans. Thisdiscussion takes the format of a dialogue aimed to elicit theviews from five Native American nurse scholars who serve asreviewers for the Journal of Transcultural Nursing. They dis-cuss major issues related to research and publication of stud-ies on Native Americans, especially those concerning healingbeliefs and practices. A major purpose of this dialogue is toassist our readers to develop a sensitivity and understandingof the concerns held by many Native Americans about shar-ing cultural information with so-called outsiders. Questionswere developed by Joyceen S. Boyle, RN, PhD, FAAN,senior associate editor, and Marilyn “Marty” Douglas, DNSc,RN, FAAN, editor. These questions were then sent to each ofthe five Native American nurse scholars, and they were askedto respond in writing. Some of the responses are overlapping;however, because they were presented in a different manneror from a different viewpoint, they were included in thedialogue.

Joyceen S. Boyle, RN, PhD, FAAN, and RoxanneStruthers, RN, PhD, posed the questions to begin the dia-logue. Dr. Struthers responded to some of the questions aswell as assuming various editorial responsibilities. The five

193

Authors’ Note: We acknowledge the assistance of Drs. Joyceen Boyle andMarty Douglas in the preparation of the format and questions posed. Dr.Boyle conceived the project and coordinated the questions and responses.

Journal of Transcultural Nursing, Vol. 16 No. 3, July 2005 193-201DOI: 10.1177/1043659605274984© 2005 Sage Publications

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Native American authors and their tribal affiliations areshown in Table 1.

Boyle: First of all, as you know, we use different terms to talk orwrite about Native Americans. Can you tell me somethingabout the current use of terms such as American Indians andNative American? Our colleagues in Canada use the termAboriginals. What about the term indigenous? What do theseterms convey to you? How do your peoples prefer to be calledby “outsiders?”

Lauderdale: When we refer to one another, we call each other In-dians. Those in my Oklahoma community comprised mostlyof Comanche, Kiowa, and Apache, have not indicated a pref-erence to being called either Native American or AmericanIndian. In my own writings, I use Native American and Amer-ican Indian interchangeably.

Tom-Orme: The terms American Indian and Alaska Native havebeen accepted among tribes and organizations across thecountry. These terms describe tribes who are federally recog-nized and have a government-to-government relationshipwith the United States. There are more than 500 such tribalgovernments. One must be cautious as there are tribes that arerecognized only by states, not federal government. NativeAmerican is a term that can be used to describe all peopleswho are indigenous to the Americas including Native Hawai-ians and peoples of Central and South America.

Nichols: I grew up using the terms Indian and American Indian.American Indian is the term used by the federal governmenton the census, so some tribes prefer that term instead of Na-tive American. I prefer to use American Indian; however, I

use other terms as I feel they are appropriate. For example, Ihave colleagues in Canada, and I use the terms First Nationsand Aboriginals; however, I also use the term indigenous forthat area. Native American and American Indian are obvi-ously not appropriate for Canadian Native people. I also usethe term Native much more broadly than it is used by others. Ifind myself using Native more often now than other terms:however, it still depends on the audience that I am addressing.Native and indigenous are terms more appropriate for inter-national use when describing original Native populations. Ihave also heard the term original people used to describe thenatives of a country. Also, Alaska Natives prefer not to becalled Native Americans or American Indian, even thoughthey are Native people of the United States. The term AlaskaNative is appropriate for this group of Natives.

In the United States, most of my colleagues use the termIndian or American Indian. I don’t find they use the term Na-tive American very much. Many of my Native colleagues usethe term American Indian. If you listen to Indian people whoare raised traditional, they say “In-dun,” and this is how theydescribe themselves. Even some highly educated Indian peo-ple say “In-dun.” In my tribe, Cherokee people are describedas Cherokee citizens, and the Cherokee Nation tribal govern-ment speaks as if its citizens are in another country. In a sense,we are because we are members of a sovereign nation so weare citizens of another nation. I was taught that I am a Chero-kee first, then an Indian, and then a U.S. citizen. This is alsowhat I teach my daughter; however, she is a member of twotribes so she is Cherokee and Choctaw. I teach her she is amember of both tribes, then she is a Native, and then a U.S.citizen. I believe that is really how most U.S. Indians aretaught to identify themselves—by their tribal affiliation andless about being an Indian.

Strickland: It is important to start this discussion about what tocall us with a reflection on values. Many of us are taught thatwe speak for no one but ourselves. That is a value I was taughtand is the position I offer in providing this response. There is atendency to try to find a “one right” way that can be used forall people. That compounds the problem and contributes toethnocentric responses.

It seems appropriate to engage the community to make de-cisions about the terminology that will be used for them. If atribal community is comfortable in using the tribal name,then use the tribal name rather than a generic one. It is veryimportant to be respectful of what an individual or group ofpeople wish to be called and only the people have the right tosay what they wish to be called in professional publications.

Struthers: Many Native Americans are reluctant to record or talkabout traditional healing practices. I wonder if we could dis-cuss some of the issues involved here.

Nichols: Indian people pass their history orally through stories.Cherokee Nation has a written language that is unique to thistribe. Cherokee Nation does have some of its traditional heal-ing practices recorded in written form. Most tribes do nothave a written language so most of their traditions are passedalong orally. Historically, when tribes made treaties with theWhite man, the White man did not honor their written wordso tribes now are hesitant to trust the written word. SeminoleNation had a taboo on learning to read and write the languagebecause the treaties they signed were not honored and thesetreaties cost them their land. Indian people are very proud oftheir tradition of passing their history and culture includingtraditional healing practices through the oral traditions. Tra-

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TABLE 1Native American Nurse Scholar Authors

and Their Tribal Affiliations and Locations

Native AmericanNurse Scholar (Author) Tribal Affiliation Tribal Location

Roxanne Struthers, Ojibwa or North central UnitedPh.D., RN Anishinabe States (5 states):

Montana, NorthDakota, Minnesota,

Michigan, Wisconsin;South central Canada(4 provinces):Ontario, Manitoba,Saskatchewan, Alberta

Jana Lauderdale, Comanche Southwest OklahomaPh.D., RN

Lee Anne Nichols, Cherokee OklahomaPh.D., RN

Lillian Tom-Orme, Navaho or Dine’ Arizona, New Mexico,Ph.D., RN, FAAN Utah

C. June Strickland, Echota Cherokee OklahomaPh.D., Ph.D.

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ditions are also passed through pictures, stories, wampumbelts, totems, smoke, sign language, symbols, and colors. Re-cording traditional healing practices in a manner differentfrom traditional ways may seem “wrong” to many Indianpeople, particularly the elderly. An Indian person may bewilling to share stories about healing practices but may notwant them written down or may not be willing to have thestory audiotaped because it is not the traditional way of pass-ing history to others.

Most Indian people do not know very much about tradi-tional healing practices. Most of the people who know de-tailed information about traditional healing practices areNative healers, sometimes referred to as medicine men orwomen. I refer to traditional healing practices as traditionalmedicine. The healers of an Indian community vary depend-ing on the tribe. Cherokees have seven clans and a medicineman for each clan; however, also there are medicine men andwomen known in the community that may or may not be clanrelated. Average Cherokee citizens may not know muchabout traditional medicine and so may not be able to sharevery much information about traditional medicine. Also,there is a belief that the person being healed does not neces-sarily need to know all the details of how the medicine man ishealing them. The person just “accepts” that the medicinewill work. Indian people do not question things as much aspeople from mainstream culture; Indian people value accep-tance more readily, so they accept that the healer or medicineman is going to heal them. The person does not need to knowthe details of why the healing occurs. So if you interview av-erage Cherokee citizens, they may just not know much abouttraditional medicine because they accept that the healerknows what he or she is doing.

Another reason why Indians are reluctant to share infor-mation about traditional medicine is because it will make themedicine bad. Medicine men or women do not share theirknowledge because it is taboo and could bring evil on them,their family, or the people they heal. Healers select to pass ontheir knowledge to specially selected persons or apprentices.This is how knowledge is passed on and to break traditionwould violate cultural norms and break the healing powers ofthe traditions.

Tom-Orme: Traditional Indian medicine (TIM) is frequently aprivate matter. The decision to use it is between the personand/or family and the practitioner. American Indian or Amer-ican Native people are often reluctant to talk about TIM, espe-cially to outsiders such as non-Indian people or Westernhealth care providers. There has been a long history of nonac-ceptance by Western providers, educators, and religiousgroups. TIM was once outlawed among tribes when theywere enslaved by Western colonists, by the U.S. government,and during boarding school days. American Indian or Ameri-can Native people have experienced centuries of suffering be-cause of their religion and TIM practices. Another reason forthe reluctance is that non-Indian people seem to be alwayslooking for entrepreneurial opportunities; and, in fact, theyhave found ways to market TIM.

Strickland: Traditional healing encompasses issues that are verysacred and personal matters. Some of us are taught that we arenot to talk about, record, or videotape certain ceremonies orspecific work. In some of our communities across the UnitedStates and in Canada, traditional healers are working withWestern health providers and exploring ways to work to-gether. Many practical issues such as liability in referrals are apart of this discussion. Respect for differences and ensuring

that the work reflects the views of the people involved in theresearch is the key.

Lauderdale: I have known two medicine men and a medicinewoman in my lifetime. All were eager to share their views ontraditional healing with nursing and/or medical students asthey believed the more health providers understand how theyuse their gift of healing, the more “complete” (holistic) thepatient’s care will be. Also they wanted the chance to empha-size why it is important to respect what healing means to In-dian people. All of them discussed spiritual, emotional, andphysical healing and how traditional Indian healing can workin conjunction with Western medicine when viewed as a so-called partnership. When there is reluctance, it usually stemsfrom being made to feel that their medicine or healing prac-tices are “unimportant to the patient’s recovery” or “not to betaken seriously.”

Boyle: In view of this reluctance to talk about traditional healingpractices, how can “outsiders,” such as health care provid-ers, be sensitive to and respectful of traditional practices?How can health care professionals appropriately learn aboutNative Americans’ traditional views so that we can learn toprovide culturally sensitive and competent care?

Lauderdale: I believe the best way for nurses to become ac-quainted with traditional healing practices is via a NativeAmerican nurse or a nonnative nurse (who is savvy in tradi-tional healing practices) who works with traditional healersin their own practice (this nurse may be a nurse practitioner asthey do a higher level of primary care, especially in IndianHealth Service facilities). Invite them to discuss how tradi-tional healers are integrated into patient care through their

Struthers et al. / VOICES OF FIVE NATIVE AMERICAN NURSE SCHOLARS 195

FIGURE 1. Cherokee Basket and Crafts With the Words Pot,Fan, and Basket Written in the Cherokee Alphabet.(Figure provided by Dr. Lee Anne Nichols, drawn byRhinda Kesselring.)

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hospitals or clinics. This can be accomplished through a con-ference or workshop format or invite them as guest speakersfor certain courses in schools of nursing, and so on. Also, ifyou have the connections within an Indian community, I havealways found medicine men and women very agreeable toshare healing practice information to interested groups ofhealth care providers, especially nurses. One suggestion is toinclude Native healers on nurse training grants as consultants.They have valuable information regarding community healthneeds and once a track record of trust is established, they arevery giving of their time and expertise.

Tom-Orme: Some facilities within the Indian Health Servicehave accepted and integrated TIM into their protocols, sothere is institutional commitment and respect. TIM resourcesare made available to patients and families who request this.

Nichols: This is a difficult question to answer. Health care pro-viders need to accept that Indians may not want to talk abouttraditional medicine with a non-Indian and may be reluctantto talk even to an Indian who is not a member of their tribe. Ithink health care professionals need to accept that some Indi-ans use traditional medicine and some do not. One cannot as-sume that all Indians use traditional medicine. I try to firstestablish whether the Indian is a traditional person or a non-traditional person, for example, what is their first language,what is their name; do they live on a reservation or in an In-dian community, which family members are with them? If Ican assess they are traditional, I might ask the person a littlebit about their Indian affiliation and indirectly identify if theyuse traditional medicine or not. I don’t directly ask themabout their health practices unless I know the person more fa-miliarly. Sometimes I do explain to the Indian person that theWhite people need to know specific information so I will beasking them some direct questions about Indian medicine andis this okay with them to ask these questions? Sometimes, theIndian understands this is information that the White healersneed. I can’t give any concrete steps to approach an Indianperson. I think it is an individual thing or at least a tribal thingin approaching an Indian person about traditional medicine.If there is a health care professional from the patient’s tribe, Iwill use that person if I need to use someone.

A health care worker can learn a great deal by visiting theIndian community and getting to know the local people. Iwould suggest to the health care worker to identify the type ofIndian community—reservation, urban, nonreservation; visitthe Indian community; visit the cultural center; attend an In-dian public event in the community; visit historical sites; talkto the people; become familiar with local customs. I wouldalso suggest the health care worker talk to the local people—ask the people how they want to be addressed; ask the peoplehow they want to be identified (Indian or Cherokee); whatkind of family system do they have? Let the people reveal in-formation about their Indian community in their own way andin their own time. Health professionals should be encouragedto read the tribal newspaper. History of the tribe is very im-portant to the people, and I would suggest that the health careprofessional make an effort to learn the history of the tribeand what the historical relationship with the U.S. governmenthas been with the tribe. I would also read about the tribe, ei-ther in books that the tribe recommends or perhaps the tribehas their own cultural center. I would recommend readingabout the Trail of Tears, ceremonies, language, traditions,public and nonpublic Indian events, religions, foods, cloth-ing, cultural values for example, native noninterference (pas-sive forbearance), and the tribal government (executive

system, principal chief, president, chairman, legislative sys-tem, judicial system). Then, the next step would be workingin the community or with patients in a health care setting.

Struthers: What advice can we provide to journal editors andreaders about articles that describe native healing practices?Are there some guidelines we can share as to what types ofNative health care knowledge would be acceptable to publishin professional health care journals?

Tom-Orme: First of all, make sure that the author has describedhow they have been given permission either through tribal In-stitutional Review Boards (IRBs) or by a TIM practitioner.

Strickland: Assurance that the contents of the manuscript wereconducted under research conditions with IRB review shouldbe essential. In this way, there is assurance the study partici-pants have given consent. IRBs must be responsible for pro-tecting the rights of individuals and groups of people in allareas of research, particularly observation and participant ob-servation research. IRBs are becoming more careful aboutthese things, and tribal communities are becoming more in-volved. In addition, reviewers should pay careful attention tohow authors of manuscripts address reliability and validity,particularly in qualitative work. There is a great risk that datacan be misinterpreted and misunderstood. Ethnocentrism canoccur in the filtering of the analysis in the researcher’s head.This results in the perpetuation of ethnocentrisms and poorquality research. Every effort must be made to ensure a trian-gulation of views and a review of the integrated findings bythe study participants as well. Journal reviewers as well as in-dividual researchers must be alert to these issues. Minoritypeople have a history of others writing about them, and thishas contributed to ethnocentric perspectives being perpetu-ated. Few have taken the time to examine the research dis-semination systems and structures that have allowedethnocentrisms to be perpetuated. It is exciting to me and ap-propriate that the Journal of Transcultural Nursing is takingthe time to engage in a dialogue about these issues.

Lauderdale: I would suggest having Native American nursescholars serve as reviewers. As long as they indicate the infor-mation is pertinent and appropriate for improving culturallycompetent nursing practice, then I believe articles describinghealth and healing practices are needed. In my specialty ofwomen’s health, I believe research findings on certain healthpractices would be most informative: These are, for example:self-care activities for women across the lifespan (e.g., preg-nancy, childbirth, menopause, elder care); Native Americanwomen and mental health issues; fetal alcohol syndrome;

196 JOURNAL OF TRANSCULTURAL NURSING / July 2005

FIGURE 2. Eagle Feather. (Figure provided by Dr. RoxanneStruthers.)

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newborn care practices; childrearing practices; and, illness inchildren.

Strickland: Tribes must designate the IRB they want to review astudy. The tribe may have an IRB, they may elect to use the In-dian Health Service or, they may choose the IRB at the insti-tution of the researcher. At least this designation is required inour area, and I assume it may be the case across the UnitedStates but can only speak of what I know here. There are stillsome potential issues with large data sets and secondary anal-yses that are coming before IRBs now. I believe it is the re-sponsibility of the IRB to address individual and tribal issues.

Nichols: The first question I would ask is: Did the tribal commu-nity give permission for this publication and did they have anopportunity to see the publication or at least review the find-ings in some manner? Was the tribal community involvedwith the development of the research or the project? Did thetribal community have any input into the development of theresearch, information, or project? Did the healers sharing theinformation understand the information was going to be pub-lished? The Indian community needs to be informed of thepublication and needs to decide if this information reflectstheir culture and tribe in a correct and appropriate manner.Sometimes, tribal communities believe it is important to pub-lish information about traditional medicine but prefer thatthey have input into how the information is going to beshared. By not obtaining permission from the tribe or a tribalentity to conduct research or studies in a community, a re-searcher may be violating the right to informed consent andthe principle of do no harm.

The second question I would ask is: Was the informationgathered in a culturally sensitive manner or in a reliable man-ner? If this is an article about traditional medicine, were thedata collected in a sensitive manner and were taboos re-spected regarding how the information was collected and bywhom it was shared. Printing information about traditionalmedicine could bring evil on the whole tribe if the informa-tion is shared in an inappropriate manner. Or the tribe mayfeel it is important for outsiders to know specific informationregarding traditional medicine. This kind of informationneeds to be gathered in a very sensitive manner, and the de-scription of how data were collected should be included in themanuscript so that readers understand the importance and re-spect that was used in gathering this information. Again, itshould be included that taboos were not broken when this in-formation was revealed.

The third question I would ask: Is this information re-vealed in other sources or in other ways? If this informationhas been published other places or in other ways, then it mightbe all right to publish the information again, giving appropri-ate credit to the original source.

Last, as a reviewer, if I am hesitant or feel uncomfortableabout certain information I have reviewed, I go to the eldersand ask for their advice and wisdom. Indian elders know thehistory and culture of the community better than anyone andoften provide very valuable advice about what is appropriate.Sometimes there is a need for certain information to be re-vealed and an elder can provide that something I may not feelcomfortable making a judgment call about.

Boyle: How would you expect your views to be different fromother Native American viewpoints? Are you aware of thevariations between and within the various tribes in the UnitedStates? If so, can you describe how views about sharing theircultural practices differ between tribes?

Lauderdale: How sensitive a tribe will be about sharing culturalpractices will depend on several things, such as what is thepurpose of why information sharing is important (for educat-ing health care providers, informing readers, etc.). It is alsoimportant to take steps to ensure that information sharing willbenefit Native people through improving nursing care or im-proving their lives in some way. It is always important for au-thors to describe how their information was obtained. Forexample, were all appropriate “approvals” in place before be-ginning to collect data? It has been my experience that “sensi-tivity levels” about sharing practices will vary greatly amongtribes.

Struthers: There are some tribes that are state recognized. Thereare groups with Indian heritage that are not recognized at anylevel. These factors increase the complexity and challenges ofdoing research with Native Americans. What are some differ-ences in views about sharing traditional information acrossthe U.S.?

Lauderdale: There are differences in views across the UnitedStates, within tribes, and perhaps among individuals. Thecore of the matter is to respect differences. The practice of in-volving Indian researchers in the review of manuscripts re-lated to Indian research is important. Maintaining highstandards of research rigor in manuscript review and assur-ances of IRB approval are essential.

Tom-Orme: Among American Indian or American Natives,there is diversity among acculturation lines; rural versus ur-ban residence/experiences; how one was raised—traditionalor not; if one speaks the native language, and, as you canimagine, worldviews vary by language spoken; whether anindividual was trained by elders; or even the background ofthe authors and/or investigators. I, personally, speak my na-tive tongue, was raised in traditional settings, maintain con-tact with my Native homeland and relatives on a regular basiseven though I live in a metropolitan area, and I practice TIM.Of course, there are variations in traditional practices by re-gion as well.

Struthers: Many Institutional Review Boards now require the ap-proval of the tribal council before approving a research pro-ject that will study the members of the tribe. It seems there areissues related to the individual research participant and to thetribe as a whole. Can you comments on these issues?

Nichols: I agree that getting tribal approval is important becauseof the historical relationship that tribes have had with re-searchers. Researchers have come and conducted studies,left, and the tribe never heard from the researchers again.Later, articles were published that made the tribe “look bad.”Tribes are just demanding that their culture and sovereigntybe respected by letting them approve of the research study first.

In theory I think that editors and publishers should requirethis type of approval; however, I am hesitant to really encour-age this type of requirement from potential authors. Gettingtribal approval can occur in many ways. Some tribes havetheir own IRBs, and the tribal council doesn’t have any say inthe approval of research projects. Some tribes require tribalcouncil approval and the tribal IRB approval from the tribe.Sometimes, the chief or president of the tribe may give tribalapproval. Depending on the research project, the tribe maynot need to give approval; however, the Indian boardingschool may be the agency that approves the project. A re-search study at an Indian urban clinic may not necessarily in-volve approval from a specific Indian group but the

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researcher may need approval from the Indian Health Serviceor maybe just from the clinic itself. I don’t know if editors orpublishers are knowledgeable enough to make that judgmentcall about what constitutes tribal or tribal council approval. Idon’t think it is a black-and-white issue. What I look for is thetribal community awareness of the study and has the tribalcommunity had input into the study? This tribal awarenessand input may be formalized or not depending on the study,the setting, the country, or community. Every effort should bemade to include the tribe in the research process, and that isthe criteria that I would encourage editors and publishers tolook for rather than approval from the tribal council becausethat approval may or may not be appropriate for the project.However, I do believe that tribal approval (in any form) is al-ways the most appropriate way to go.

Lauderdale: Yes, I certainly agree tribal approvals are necessary.Without tribal approval, conducting a research study wouldbe viewed, in essence, “to do something against their will.”There are still feelings of “being used” for research purposesdating back to the early 1900s. Tribes did not understand “in-formed consent” and therefore did not understand for whatpurpose they were being studied, what the findings were, orhow the information was to be used. Many times, tribes laterfound out the findings were used for monetary gain by the re-searcher. Tribes came to believe that they were taken advan-tage of and that there was “no benefit” to participation inresearch studies.

There is no reason for a professional journal to seek tribalconsent before publishing a manuscript because a credible

nurse researcher would be required to obtain this prior to theresearch study being initiated. Although I now understandthat it is becoming quite common for journals to ask for acopy of the IRB approval; I know the Journal of TransculturalNursing requires a copy of IRB approval before they accept amanuscript. However, to return to the topic of tribal consent;even as an Indian, tribal consent is an arduous process as youmust get tribal health board consents from each tribe to bestudied as well as informed consent of each participant. Youmust also have consent from the Indian Health Service or In-dian clinic where you are collecting data. I don’t believe jour-nals or publishers should be required to obtain theseapprovals as it is the clear responsibility of the researcher orinvestigator. The informed consents obtained by the investi-gators should have language describing how the informationis to be used (e.g., presentations, written reports, publicationsin refereed journals, etc.), and that will cover the publishingcompanies or journals. Health boards, institutions, and par-ticipants all must approve of the research purpose and howthe information will be used. That should be sufficient.

In the case of nonresearch reports or manuscripts, the fol-lowing procedures should be followed:

1. The author(s) would need to state up-front exactly howthis information was collected and under what circum-stances. It should be clear that the information was ob-tained under nonresearch conditions and that the informa-tion as reported is solely the interpretation of the author.There should also be a clear statement the informationwas not accepted or approved by those being observed orinterviewed, in other words, a disclaimer as such.

2. The author(s) need to tell readers if the individuals beingobserved and/or interviewed were aware of the observerand if they understood how the information collectedabout their behavior would be used.

3. Of course, it should be very clear if any kind of consentwas obtained for the observations, interviews, etc.

However, having said all of those things, I still believe thatthe majority of tribes would take issue with an outsider’sviewpoint being attributed to them, especially when dealingwith sensitive cultural healing practices. I think the journalthat published such an article should consider requiring theauthor to get a written consent, on a case-by-case basis. In re-ality, if published information and/or findings are to be con-sidered to be “culturally sensitive,” then you must considerthe moral, ethical, legal, and cultural implications, especiallyif it is not a research-based report or article.

Strickland: Community-based participatory action research isthe model I use in working with tribal communities. My re-search work is in prevention, the behavioral sciences, andcommunity health; and thus this model is what I teach andpractice. The community drives the agenda and is involved inthe design, implementation, and evaluation. The major fund-ing goes to employ people in the community and in buildingcommunity capacity to conduct research. There is, therefore,never a question about tribal council involvement. Often onehalf of the planning committee for my research comprisestribal council members.

Tribes are becoming very wise about the research thatthey will permit. Tribes can now designate the IRB they wantto conduct the review and must give their consent for the insti-tution that is chosen. The IRBs, however, often still are geared

198 JOURNAL OF TRANSCULTURAL NURSING / July 2005

FIGURE 3. Cherokee Woman with Drum. The word drum, writ-ten in the Cherokee alphabet, is below the figure.(Figure provided by Dr. Lee Anne Nichols, drawn byRhinda Kesselring.)

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to address the individual consent rather than the broader tribalissues. We all have a continuing responsibility to teach othershow to respect “tribal” matters. For example, consents thatwe prepare in work with tribal communities should addresstribal rights, as well as individual rights, in relation to man-agement of the data, publications, and presentations. Con-sents must be written in such a way that anyone canunderstand them. Approval may not always have to be at thecouncil level; many tribes have guidelines about approvalsand dissemination of research. The researcher has to knowhow the tribe wishes to address the matter of consent and dis-semination. Professional journals are, however, in a strategicposition and have a responsibility to raise concerns about theprotection of the rights of vulnerable populations.

Special attention should also be given to secondary dataanalysis and related publications. An area of major concern issituations in which researchers collect data for large studiesfrom Indian tribes that become a part of a larger data set thatothers might access and conduct a secondary analysis, with-out the original people who participated in the research know-ing about the larger data sets and the secondary analysis. Asyou know, it is now a trend for IRBs to require additional ap-provals if the researcher(s) uses a different method to analyzedata originally collected for another purpose. Consents toparticipate in a study should protect the rights of a tribe andensure that additional approvals be obtained when the investi-gator wants to use the data for secondary analysis or a differ-ent purpose at a later time.

Tom-Orme: It is important to emphasize that IRBs require the ap-proval of the tribal council before beginning a research pro-ject that will study members of their tribe. All college anduniversity IRBs should require tribal approval when someoneconducts research on tribal land or jurisdiction or conducts astudy about a tribe. If an author or investigator submits amanuscript or writes about a tribe without tribal approval,these authors or investigators have violated agreed-on re-search ethics. They have no authority to conduct this study orreport their findings.

All tribal IRBs or tribal councils (if there is not a formalIRB) must approve any information written or spoken aboutthem. This includes publications, papers, or oral presenta-tions, posters, and so on. Remember tribes are sovereign na-tions, and they have the right to control informationdistributed about them and their people. Tribal approval is notrequired if an American Indian or American Native person onhis or her own agree to participate in a study on their own, asan individual. I serve on the National Indian Health ServiceIRB and assist with training, and I know that these are reallyimportant and sensitive issues.

Boyle: Do you think this is a feasible requirement, that is, wouldit prove difficult to obtain such approvals from the tribalcouncils that you work with?

Nichols: Editors or publishers might want to use the guidelinesthat I discussed in the previous section. Getting tribal ap-proval does take an average of 1 to 2 years and sometimes lon-ger. This is not to say a researcher should not get approval;however, it does take time. Again, I think that tribal approvalis different for each setting and community, and every effortshould be made to include the tribal setting or community inthe research process and editors and publishers should lookfor that tribal involvement either from the setting, communityor individual.

Tom-Orme: It is a very difficult process to obtain Navajo Nationapproval as one has to get approval by a chapter, individual,health board, IHS facility, Area Health Board, Navajo Nation,and perhaps the national Indian Health Service IRB. If the re-search is an anthropological study, there is a different process;for example, the Navajo Nation IRB might not approve astudy if there have been too many studies on certain topics,such as diabetes. Any resources introduced to the Navajo areexpected to remain there after the researcher leaves—for ex-ample, computers, technology, and so on. All outside entitiesare expected to hire Navajo staff, train them, and so on. And,within the Navajo Nation, there is an organization of the Na-vajo medicine men. This organization must be consulted onany study that involves traditional Indian medicine in any way.

Boyle: Can you suggest other methods to ensure that the leadersof the tribe are aware of and approve of the knowledge beingshared with those outside the tribe? For example, rather thanhaving a consensus of the full council, could the designatedleader’s approval be sufficient? Or is this contrary to the wayin which decisions and approvals are given?

Tom-Orme: One would have to work with the tribe and figurethese things out as they may vary by tribe. Tribes do not like togive blanket approvals. It takes time for a researcher to beseen, heard from, and trusted before approval is given inmany places. Tribes do not like “helicopter” research. This isknown among tribes as researchers coming in (flying in), tak-ing data, leaving (flying out), never to be heard from again.

Nichols: Research conducted with tribal people varies from set-ting to setting and institute to institute. The researcher needsto be aware of how a research study gets approved of in atribal community. For instance, if a researcher wants to con-duct research on an Indian reservation, more than likely theresearcher has to go to the tribe, either the tribal IRB, the In-dian council, or the chief (president, chairperson, governor)of the tribe, and get direct tribal approval. If a researcherwants to do research in an urban setting, the researcher mightgo to the local Indian center for approval and maybe a localtribe. If a researcher wants to do research at an IHS facility,the researcher may need to get approval from IHS and fromany tribes represented at the facility. Usually, a researcher iswise if he or she goes to the tribal officials if their populationinvolves mainly one tribe; however, if it involves many tribes,it may be harder to identify which tribe is the appropriate en-tity to get approval from. That is why, sometimes, a re-searcher might want to go to the intertribal council, an Indiancenter, Indian Health Services, Indian Affairs Commission,or an Indian organization of some sort to get local tribal inputand approval. Tribal council approval may be only appropri-ate for some tribes and in only certain settings. Again, gettingtribal approval is not a black-and-white issue; it is complexand time-consuming.

COMMENTS AND SUMMARY

We certainly want to thank the contributors for providingthoughtful and genuine responses to our questions. This dia-logue is rich in content and is pertinent to researchers, pub-lishers, and readers of manuscripts related to healing beliefsand practices of Native peoples. The topic of traditional heal-ing practices, while somewhat new to nursing, had its begin-nings among disciplines such as anthropology and sociology.

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The current fashion that cloaks this topic area is complemen-tary and alternative medicine.

Given all of this, this dialogue points out salient tribalissues related to the area of research. Tribes are demandingtheir culture and sovereignty be respected by allowing themto approve any research before it is conducted. Tribes, as sov-ereign nations, have the right to control information distrib-uted about them and their people. The core of the matter isrespect; the research projects must respect tribal rights as wellas individual rights.

As you can see, there is no one answer about which term touse when one talks about Native peoples. Some of us have nopreference over Native American or American Indian. Thepeople may call themselves Indians or “In-dun.” However,American Indian or Alaska Native refers to those federallyrecognized tribal groups in the United States. In Canada,original inhabitants are called First Nations or Aboriginal.Native American can be used to refer to all indigenous peo-ples of the Americas. Also, Native or indigenous are usedinternationally when describing original Native persons.

It was pointed out that American Indians may prefer to becalled by their tribal name. My tribe has three names—Ojibwa, name given by Americans; Chippewa, name givenby French; Anishinabe, name the tribal people call them-selves. Dr. Nichols was taught she is a member of the Chero-kee Nation first, an Indian second, and then a U.S. citizen.Thus, Native people living in the United States are citizens oftwo nations.

Oral stories are the preferred method of transmitting allknowledge and information among Native peoples. Thus,many elderly individuals may not want traditional healingpractices recorded in ways that differ from their traditionaloral traditions. Native healers (medicine men and women) are

the keepers of the healing knowledge. Many tribal peoplemay not know much about traditional healing practices andmay not feel they need to know how the healing is done. Theyjust trust that it works.

Traditional Indian medicine (TIM) is a term used for Nativehealing. It is sacred, private, and personal. Thus, sometimes itmay not be talked about, recorded, or videotaped. TIM hasbeen sought by non-Natives for entrepreneurial opportuni-ties. In any case, TIM has a long history that continues to thisday of nonacceptance by Western medical providers who arecommitted and taught via science and thus may not readilyaccept other healing methods or ways.

Dr. Lauderdale notes that often medicine men and womenare eager to talk about how they use their gift of healing andwant to work in conjunction and partnership with Westernmedicine. Some facilities in the Indian Health Service haveintegrated TIM into their protocol and resources are madeavailable to patients and families who request this healingapproach.

However, all Indians do not use the traditional healingpractices. If they do, they may not want to share their experi-ence of traditional healing practices with a non-Native. It isnot appropriate protocol to ask an Indian directly, unless youknow him or her, about the traditional health practices. Get-ting to know and utilize the wisdom of a Native nurse or non-Native nurse who is knowledgeable about traditional healingpractices will assist one who wants to learn more. IncludingNative healers on grants as consultants can provide expertiseon community needs.

To learn more about native customs and practices,researchers need to make extra efforts to learn about the peo-ple they plan to study before beginning the formal researchstudy. The history of the tribe is very important to Indian peo-ple. Reading information about tribes is a good way toacquire information. Often, the tribal paper will provideimportant facts to know and it is highly recommended that aresearcher read and learn as much as possible before begin-ning the research project.

Tribal approval is not required if an American Indian orAlaskan Native person, as an individual, agrees on his or herown to participate in a study. However, when writing abouttraditional healing practices, documented permissionthrough an IRB is a must. As was noted previously in the dia-logue, there are several IRBS from which a researcher mayneed to seek approval. These include tribal IRBs, IndianHealth Services IRBs, and the research institution IRB, or allof these. Tribes may also require the research to be approvedby the tribal council, a chapter, a local health board, and/or anarea health board, and so on. In an urban setting, permissionmay be granted differently. As you can see, many avenuesexist among tribes to grant research approval. It can be anarduous process, and this process can take 1 to 2 years. Thebottom line is a researcher must be aware and knowledgeableabout how to get a research study approved in a tribal commu-

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FIGURE 4. A Pair of Moccasins. (Figure provided by Dr.Roxanne Struthers.)

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nity and respect the reasons why Native peoples may becautious about those research studies.

Some of the problems posed by analysis of large data setsand/or a secondary analysis were discussed by Dr. Strickland.Secondary analysis is an issue, as the original persons whoprovided the data for one purpose do not have a way to pro-vide consent again. How reliability and validity are addressedin a research study becomes extremely important. Researchrigor decreases the risk of data misinterpretation and misun-derstanding that can perpetuate ethnocentrism and poor qual-ity research. These are the kinds of problems that have mademany Native peoples are extremely sensitive and cautiousabout research studies.

Finally, sensitivity levels about sharing healing practicesvary among tribal groups. The question always arises, whyand for whom is the information being shared? Sometimesthe researcher benefited monetarily through tribal research—but without benefit to the tribe. It is paramount to ensureinformation sharing benefits tribes by improving health andnursing care or in other ways.

Although this dialogue has answered some questions, ithas posed others. The context for conducting research amongNative peoples is constantly changing and it behoovesresearchers to keep abreast of new trends and directions aswell as why such changes occur. The dialogue points out theimportance of beginning to talk among ourselves about someof these issues. We realize that what we have discussed is notthe final word but has only served to further expand thisdiscussion.

Roxanne Struthers, PhD, RN, is an assistant professor in theSchool of Nursing at the University of Minnesota in Minneapolis.She received her PhD in nursing from the University of Minnesota atMinneapolis. Her research interests include American Indianhealth, including Type 2 diabetes, cigarette smoking, andindigenous traditional healing.

Jana Lauderdale, PhD, RN, is an associate professor, assistantdean for Cultural Diversity, and program coordinator for the Fisk-Vanderbilt BSN Program at Vanderbilt University in the School ofNursing in Nashville, Tennessee. She received her PhD in trans-cultural nursing at the University of Utah in Salt Lake City. Her re-search, teaching, and clinical interests include culture & women’shealth issues and minority nursing education issues.

Lee Anne Nichols, PhD, RN, is an assistant professor in theSchool of Nursing at the University of Tulsa in Tulsa, Oklahoma. Shereceived her PhD in clinical nursing research at the University ofArizona in Tucson. Her research, teaching and clinical interests in-clude American Indian parenting, American Indian families with de-velopmental disabilities, and American Indian Nursing. She is also agrant reviewer for Division of Nursing, gives national presentationson American Indian Families with and without disabilities, andAmerican Indian family model building.

Lillian Tom-Orme, PhD, MPH, MS, RN, FAAN, is an assistant re-search professor in the Huntsman Cancer Institute at University ofUtah, in Salt Lake City. She received her PhD in nursing from theUniversity of Utah in Salt Lake City. Her research and teaching in-terests include community health, diabetes, Indian health, andtranscultural nursing.

C. June Strickland, PhD, RN, is an associate professor in the De-partment of Psychosocial and Community Health Nursing in theSchool of Nursing at the University of Washington in Seattle. She re-ceived her PhD in higher education, policy and governance from theUniversity of Washington in Seattle. Her research, teaching, andclinical interests include community-based participatory research(CBPR) prevention research in American Indian reservations in thePacific Northwest, and cancer and suicide prevention. She serves asa reviewer for a number of professional journals and reviews grantapplications for the National Institutes of Mental Health and Na-tional Cancer Institute; she is also a member of the National CancerInstitute (NCI) Indian Research Network, a past president for theNational American Indian, Alaska Natives Nurses Association,cochair of the Nominations Committee for the American IndianCaucus of American Public Health Association, and a member ofthe Advisory Board for the Intercultural Cancer Council (ICC).

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