Experiences of being old and receiving home nursing care . Older South Sami narrations of their experiences — An interview study

The Sami people who are the natives of Scandinavia are not a homogeneous group. They consist of different groups of Sami populations of which the South Sami population are one small group. For the South Sami this means a problem; they have to struggle against a general ignorance about the Sami people and culture, which also may affect received home nursing care. The aim of this study is to describe individual South Sami experiences of being old and receiving home nursing care. A sample of 10 older persons with South Sami background was chosen for this study. Narrative interviews were conducted and qualitative content analysis was used to identify and categorize primary patterns in data. The experience of being an old person with South Sami background who receives home nursing care was understood through the use of the following four themes developed from the informants’ own narratives: “Experience of losses in life”; “Feelings of being less valued”; “Feelings of gratitude”; and “Experience of meaning in daily life as old”. The main finding is that the South Sami population still is exposed to an ongoing subtle colonisation. Therefore, it is important to prepare and teach nurses who work in the South Sami area in cultural care, traditional values and beliefs specific to the South Sami population.


INTRODUCTION
Worldwide, there are almost 400 million indigenous people who often suffer from worse health status compared to non-indigenous people [1,2].The Sami people are the natives of Scandinavia, and they live in northern areas of Norway, Sweden, Finland and Russia's Kola Peninsula [3].The size of the Sami population is approximately 80,000 -100,000 [4].However, the Sami population is not homogeneous; it consists of different Sami people of which the South Sami population is one.This population consists of approximately 3000 persons living in the middle of Sweden and Norway and should therefore be seen as a minority inside the Sami population.
Research shows [5,6] that the Sami population in the Nordic countries have a uniquely positive health situation compared to other indigenous people in the Arctic regions.According to Gaski et al. [7] people with Sami background have similar health status as the rest of the population with similar life expectancy and mortality patterns [8].Among others, Symon and Wilson [5] contend that the explanation could be that the non-indigenous population in the region has comparable living conditions as the Sami.A possible interpretation of the positive Sami health is that Sami people have lived side by side with the majority population in multi-ethnic communities with an almost equal standard of living [9].
In Norway the South Sami population is estimated at 1500 people, and is similar to other ethnic minorities and native people who have been exposed to assimilation, racism and ethnic discrimination [10].Historically, people with Sami background have been exposed to discrimination and a sort of inner colonialism through the so-called Norwegianisation Process, a process that went on from 1850 to 1980 [11].As a consequence of this, many of the people with Sami background lost their language, culture, religion and identity [3].It seems as the South Sami people have, in many respects, lost their homogenous cultural identity through more than a hundred years of repression of their Sami identity from the Norwegian government [3].The exposure to discrimina-tion through the Norwegianisation Process when speaking and teaching of Sami language was either neglected or prohibited, and led to a loss of the native South Sami language within a single generation [12].Today, the density of Sami is low in the South Sami area and rather few speak Sami as their first language (approximately 15%) compared with 80% in the Sami highlands in the northern part of Norway.The fact that they are a minority in the minority means that the unique South Sami culture is masked by the northern Sami culture.In spite, resistance against Norwegian colonisation maintenance of South Sami culture and identity compared to the northern parts of Norway have been unsuccessful.Reasonably, this had led to marginalization of people with South Sami background both in the Norwegian society and within the Sami society.Therefore, the colonisation process had been very "good" in the South Sami areas and the Norwegian society's great influence on the South Sami identity had led to loss of culture, language and worldview.
Generally, there is a lack of knowledge about Sami culture within communal health and social services.For the South Sami population, this has created a two-sided problem; firstly, they have to struggle against a general ignorance about the Sami people and culture and, secondly, against the understanding that being a South Sami means to be a minority within the minority [13].The latter situation also means that there are other demands and problems connected to the South Sami population that are not recognized in North Sami areas.For example, in the North Sami area, the language is the main problem in regards to Sami contact with health and social services.For the South Sami population, the language is no problem when all South Sami residents speak Norwegian well or satisfactorily.Instead, the main problem for the South Sami group is its loss of traditions, e.g.access to Sami food when being admitted to health care institutions [14].
To identify oneself as belonging to a minority population is relative, i.e. a minority can only exist in relation to a majority and vice versa [15].It is in relation to the Norwegian population that the Sami population can be identified as a minority.This means that belonging to an ethnic group is not enough for someone to be identified as belonging to a minority group.It is the number of people in relation to geographic borders that places people in majority or minority groups.A problem for smaller Sami groups, as the South Sami group, is that they are seen as one heterogeneous cultural group.This may result in different communal services failing to understand that they actually have a Sami minority population within the specific municipality.Culture appears to be perceived as relevant only to people who are different from the majority.For many Norwegians, the Sami population is the same as the people living in the most northerly part of Norway.To be a minority within the minority means that the group has to struggle for acceptance within their "own people" before they can be accepted by the larger society [13].
The South Sami society is characterized by variety and its people must be treated accordingly rather than stigmatized as a group [16].Many South Sami individuals report about this difference; they experience little cultural understanding from the society, leading to individual feelings of powerlessness and insecurity in relation to Norwegian health and social services [14].In spite of this, health and social services in municipalities with South Sami populations have shown no or little interest in or knowledge about South Sami culture [14].People working in the health and social service sector with South Sami populations usually stress that they do not make any distinction between Sami and Norwegian users.However, this is usually the problem.South Sami users are made to feel invisible, which often obstructs them from verbalizing their health problems [14].Despite improved health among the Sami population, research is needed to highlight Samis' view on the health and social services they receive.No studies have been found that have focused on the older South Sami people's view on the health services they receive in the municipality.Therefore research is needed to illuminate their situation.The aim of this study was therefore to describe the experience of individuals with South Sami backgrounds in terms of being old and receiving home nursing care.

METHODS
The study approach used a naturalistic qualitative methodology with in-depth interviews.In this way the individual and combined experiences of 10 older persons with South Sami background was explored.The naturalistic inquiry is an inductively way to capture life experiences and to encourage the participants to talk about their lives to understand how daily life is described from his or her perspective [17].

Participants
A sample of older women (n = 7) and men (n = 3), in the age of 72 -88 years, were chosen for the study.All informants lived alone, except one who lived with a spouse.They all received or had received home nursing care.Some had visits from the home nursing care several times every day, and others had visits once a week.The informants were informed verbally and by written information about the purpose of the study.

Interviews
The first author conducted narrative interviews [18] dur-ing Spring 2010 and Spring 2011 when older people with South Sami background were asked to narrate stories regarding specific themes:  Please, can you tell me about your experience of received home nursing care? Please, can you tell me about how you experience being an old South Sami today? Please, can you tell me about how you experience living alone?Sandelowski [19] stresses among others, that using stories as data collection method gives important information about the person who narrates (we are the stories we tell), and that an individual's story includes the past, present and future.During the interviews the interviewer asked clarifying questions only when she did not understand, or when she wanted the informants to develop their stories.The interviews were carried out according to the informants' preferences in regards to place and time.The interviews, which lasted 85 -176 minutes, were recorded and transcribed verbatim by the first author.

Analysis
Content analysis has been defined as "the process of identifying and categorizing the primary patterns in data" [18].According to Krippendorff [20], content analysis is appropriate for analyzing text from interviews.Content analysis in this study has been carried out in the following way: the interviews were read thoroughly several times in order to get an overall picture of the contexts.Topics identified were used to organize the content in a meaningful way.Meaning units created by one or more sentences related to the different topics, were identified and condensed to shorter formulations.Subthemes were formulated for subsequent abstraction into themes.Finally, an interpretation of the whole was made [18].The first author analyzed.Thereafter, the second and a third author evaluated the text and the analysis in order to address the question of trustworthiness and discuss possible interpretations until a consensus was reached [18].

Ethical Considerations
The informants were thoroughly briefed beforehand and guaranteed confidentiality.Each informant gave their informed consent to participate before they participated in the study.Permission for research was granted by the Norwegian Social Science Data Services (No. 24304) and carried out in accordance with the Declaration of Helsinki [21].

FINDINGS
In this study, individuals with South Sami backgrounds' experience of being old and receiving home nursing care was understood through a qualitative content analysis from which four themes emerged: "Experience of losses in life"; "Feelings of being less valued"; "Feelings of gratitude"; and "Experience of meaning in daily life as old".

Experience of Losses in Life
To manage their daily life, informants need frequent help from others.Some get most of their help from formal caregivers, while others get it mostly from informal caregivers.They all want to live as long as possible in their own homes, but they see the possibility of being forced to move to a nursing home in the future.When they talked about their earlier life, they talked about their childhood and youth.Most of them shared that they grew up in a road-less land, and were used to being one with nature and one with their relatives.Nowadays, it was not so; their relatives were experienced as busy with jobs and a family and had little time for the informants.One informant said: "…you miss it, but you know, you get used to being alone … this is the fate as an old Sami nowadays".
In their stories all informants expressed a strong connection to nature, and that the nature had been a major part of their lives since they were born.Now, as they are older, they cannot go out into the nature as they used to because of their impairments, which limit their participation in life and their connection to the nature and reminds them of feelings of estrangement in society.
In connection to their stories about a happy past as a child or in their youth, they often mentioned the loss of their language.Some of them told about a time when they were not allowed to speak the language or practice Sami traditions.Almost all had negative past experiences from when the society had sought to marginalise them.In their narrations, informants said they, in the past, had not been seen as equals by their Norwegian neighbours.For other informants their impairment of being old mirrored their participation in the community as outsiders in the society.Nowadays, impairments led to a reality where they could not participate and perform as before.Informants said they could no longer participate in activities such as reindeer herding, hunting and berry picking as before.This resulted in loss of relationships with their families and friends.And for some, the loss of relationships led to feelings of loneliness, while others liked or appreciated a life in solitude because solitude meant that they could do the things they wanted to do."There are many things I miss in my life now, but I have learned how to manage it…"

Feelings of Being Less Valued
During the interview many of the informants were undermining their own value and felt that other service us-ers should be given priority before them.Sometimes nurses offered them more help than they needed even if they did not request more.This made informants upset and to their opinion nurses ought to understand that other clients needed help and service more than them.Their own health was not important and their age was the determinant to their problems.One of them said: "You have to realize that it's not only you who need[s] care … You know, you think that you can't care about a little headache, a little pain … because you are getting old".
In their stories it became clear that they often did not use their safety alarm, even if they were falling.One informant told that she would rather wait for her daughter to come to her than bother home nursing care even if she had to wait for several hours, instead of using the safety alarm.Informants also made it clear that they looked up to the formal caregivers and saw them as kind and gentle and felt they treated them as equals.They also meant that the caregivers were more intelligent and therefore were more important compared to them.One of them expressed it in this way: "I'm old and silly, so I can't be to demand anything.They, the nurses are intelligent young people".

Feelings of Gratitude
All of the informants were grateful to have home nursing care and for the help they got.Nowadays, when time had change, they experienced that they were treated as equals to other residents in the municipality.Now they were a Norwegian among other Norwegians.Their gratefulness towards the home nursing care and their history as marginalised had made them satisfied.One of them said: "They treat me as a common citizen of the country.That's good, so I can't complain about that".
The informants were used to a life with many duties while growing up and helping others; therefore, receiving help was a strange feeling for them.Receiving care made them feel preferential but there is something that compelled informants to not express their needs to the home nursing care.The visits from home nursing care were the 'peak of the day' and informants talked about different things the caregivers liked.They felt that the gratitude for received help and the fact that they finally were considered equal members of the society meant that they could not demand anything special.After all, they had a South Sami background and should be satisfied.One informant said: "I'm just an ordinary person, so ..

Experience of Meaning in Daily Life as Old
Almost all of the informants stressed that they were meant to be a Sami, which was their only choice and should so be.Some of them also emphasized that the life as a South Sami has become better and better and they were more accepted nowadays.One informant expressed that they went from being valued as nothing, to experiencing that they were worth something after all."I think it's so good to be old.Neighbours talks to me, and stay in touch.Nobody cares if I am a Sami nowadays".
Informants had accepted their life with all its changes and that they could not do the same things they did before.They said they had accepted their life as it was and they were grateful for every day they got.One said: "I feel good.I think I have it better and better, the older I get".Now, as older South Sami, they experience happiness and a life of loneliness did not control their own time.One said: "One must take life as it comes.Now I fill my time with reading and I also have a little shed where I can do some woodworking".

DISCUSSION
The experience of being an old person with South Sami background who receives home nursing care was understood in this study through four themes developed from the informants' own narratives.When judging the result of the content analysis it is important to consider that the individuals have described how they in their past were deeply humiliated by the Norwegian society and Norwegian people in their neighbourhood.In their present they seem to be treated as equals to other citizens in the municipality.Their historical and present experience creates life patterns that influence their health and experience of health services [22].
In the present study, as in many other studies [23,24], it is obvious that growing older means meeting different losses in life.For example, older people experience: decline in physical capacity over the years [24]; loss of independence when receiving formal care in their homes or institutional setting [25]; and loss of purpose in life with increasing age [26].Informants, in our study, were living with many different losses.All of them had "experience of loss in life", which contained, among other things, loss of physical body and loss of nature that led to loss of participating in the community in the similar way as the marginalization experiences from their youth.In conformity to Hedlund and Moe [14] South Samis' loss of traditions is the main problem for the interviewees.They mentioned that loss of their South Sami language led to an alienation from their own South Sami culture.Similar to Appiah and Gutman [27] who discuss the concept of "culture" as a common culture that shares a language and participates in mutual expectations and understandings.Even if our interviewees experienced themselves as alienated from their culture and traditions they all emphasized that outdoor living and being close to the nature forms the basis of their wellbeing [28].As older South Sami in general, they dreamed about the past, and longed for a life up in the mountains [29].However, their physical impairments and need of nursing care influenced their life and participation in traditional life and work negatively.
In their stories the interviewees mentioned a sense of a life that lacked meaning and encounters where others did not consider them worthy of respect, which led to feelings of being less valued.Experience of belonging to a minority group lead to negative psychological wellbeing [30].Health care providers who focus exclusively on minorities, such as the South Sami, as minorities or as "the different others" risk seeing their clients only as products of their culture leading to dissatisfaction when they had to explain their Sami culture every time they used health or social services.Instead, sharing a cultural identity requires knowledge of transcultural nursing concepts and principles [31].
In the South Sami areas, that is, in the middle of Norway, the difference between the South Sami and the Norwegians are not always obvious [32].The South Sami population has been affected by assimilation, stigmatisation and discrimination, which all should be seen as dimensions of colonisation [33].Older South Sami have lived their life in an area of tension between these colonisation forces.Reasonably, distance between people with South Sami backgrounds and Norwegians arrests all dialogue [34] and forces South Sami to adapt to the Norwegians' view of themselves.In our study it is clear that our old South Sami informants most frequently used a "palliative coping style" in relation to health service providers such as choosing a passive approach, for example, finding an anti-aggressive relationship with the health service staff [35].Through not bothering the health care staff, looking up to them, and behaving in a kind and gentle manner, the old South Sami manage to make the health service staff treat them as equals.
To experience oneself as equal to other citizens meant "feelings of gratitude".In their everyday life interviewees were relatively independent and therefore did not demand anything from formal caregivers.They expressed thankfulness about the received nursing care.Logically, even if the South Sami population have similar health status as the rest of the population, their gratitude could be seen as a result of hundred years of colonialism.In their encounter with the mainstream health care service, informants met structures of discrimination where nurse's risk continuing to be agents of colonisation and the old South Sami service users are the victims in a subtle colonising system.People working in the health and social service sector in South Sami areas usually stress that they do not make any distinction between Sami and Norwegian users.However, this is usually the problem.South Sami users are made to feel invisible, which often risks obstructing them from verbalizing their unique health problems [14].By seeing the old person with South Sami background as an "old Norwegian" or as an "old Sami" the nurses neglect the South Sami cultural identity and worldview.Instead, the core of nursing should lie in the actual encounter with the unique old South Sami [36].The culturally competent nurse may strive to provide optimal holistic, culturally based care, which helps the client to care for himself within a familiar, supportive, and meaningful cultural context.
Informants seem to accept their lives as South Sami, with their losses, and experienced meaning in daily life as old South Sami today.Several of them had experiences of bullying in their childhood and youth and see their situation today as improved.They had accepted their South Sami heritage and found meaning in their life through acknowledging traditional Sami activities [37].Growing old means, for all people, to be in a phase of change for the whole person that forces them to deal with changes that limits and prevents them from being what he/she used to be [24].In this study, the informants said they accepted their new lives as old and filled their everyday life with different activities.Some informants read, some did handicrafts and all were looking forward to visits from both relatives and formal caregivers.Finding the positive things in life is important when it gives life meaning [37].This was something most of the informants in the present study managed.
The main finding in this study is the on-going subtle colonisation, which the South Sami population still is exposed to.Therefore, it is important to prepare and teach nurses who work in the South Sami area in cultural care, traditional values and beliefs specific to the South Sami population.This is important because such awareness is seen as the gateway to cultural competence [38].Through making traditional values and beliefs visible, culturally meaningful health promotion strategies may be developed.Our opinion is that our findings are transformable to other ethnic minorities such as immigrants and refugees who are a growing population in the Western society, groups with unprecedented cultural diversity who nurses face daily in their work.

Methodological Considerations
This study focused on how home-living older people with South Sami background experienced their life situation as an older person, and the home nursing care they received.The strength of qualitative research is its flexibility and insight into complex phenomena, but is limited by small samples and may not be generalized.In this study, the individuality of each person who participated was important.When reading this paper it is important to remember that the findings presented are just one of many possible interpretations and that the present study is not an attempt to evaluate formal care.The data are based solely on our informants' personal experiences and are discussed strictly from their perspective.Therefore, the intention of this paper is not to generalize the findings and make generalizations about the group of old South Sami, but simply to illustrate the complexity of the experiences of older persons with South Sami background.It is for the readers of this research to judge how far our findings can be transferred to another context.To promote this, we have tried to give a detailed description of the study research context and methods, relying on our abilities as researchers to read and discuss the analysis.

CONCLUSION
When working with minorities in nursing, cultural competence is a cornerstone.The culturally competent nurse needs to understand his/her own views of the world and those of the client, while avoiding stereotyping and misapplication of scientific knowledge.Cultural competence could be seen as obtaining cultural information and then applying that knowledge.This cultural awareness allows nurses to see the entire picture and improves the quality of care and health outcomes.Developing an understanding of what it is like to be an old South Sami who receives home nursing care is important for the nursing profession in order to provide adequate health care.Further research is needed to focus on the ways in which the nurse's work influences older South Samis' daily life, and on the best practices for caring for older South Sami persons with respect to their cultural values and beliefs, despite the priorities of the nurse's working day.