http://tcn.sagepub.com Journal of Transcultural Nursing DOI: 10.1177/1043659602250639 2003; 14; 139 J Transcult Nurs Carol Savrin Sharon M. Weyer, Victoria R. Hustey, Lesley Rathbun, Vickie L. Armstrong, Samantha Reed Anna, Jeanne Ronyak and A Look Into the Amish Culture: What Should We Learn? http://tcn.sagepub.com/cgi/content/abstract/14/2/139 The online version of this article can be found at: Published by: http://www.sagepublications.com On behalf of: Transcultural Nursing Society can be found at:Journal of Transcultural Nursing Additional services and information for http://tcn.sagepub.com/cgi/alerts Email Alerts: http://tcn.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: http://tcn.sagepub.com/cgi/content/refs/14/2/139 Citations by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://www.tcns.org http://tcn.sagepub.com/cgi/alerts http://tcn.sagepub.com/subscriptions http://www.sagepub.com/journalsReprints.nav http://www.sagepub.com/journalsPermissions.nav http://tcn.sagepub.com/cgi/content/refs/14/2/139 http://tcn.sagepub.com 10.1177/1043659602250639 ARTICLEJOURNAL OF TRANSCULTURAL NURSING / April 2003Weyer et al. / A LOOK INTO THE AMISH CULTURE A Look Into the Amish Culture: What Should We Learn? SHARON M. WEYER, MSN, RN, NP-C Case Western Reserve University VICTORIA R. HUSTEY, MSN, APRN, BC Rainbow Babies and Children’s Hospital, University Hospitals of Cleveland LESLEY RATHBUN, MSN, RN, CNM VICKIE L. ARMSTRONG, MSN, RN SAMANTHA REED ANNA, MSN, RN JEANNE RONYAK, MSN, RN CAROL SAVRIN, ND, CPNP, FNP-C Case Western Reserve University It is important to understand the Amish culture in order to provide appropriate, acceptable, and accessible health care to this culturally diverse group. A case study pertaining to the care of a dying elderly Amish woman living in a rural Amish community is examined. This allows for exploration into the world of the Amish community in greater detail. Their overall beliefs, values, and behavior are discussed as well as how their lifestyle affects their health care decisions, access to health care, and reimbursement of services. Nurse practitio- ners can offer culturally sensitive and appropriate health care to the Amish population by recognizing important cul- tural values that have survived for more than three hundred years. Keywords: Amish culture; nurse practitioner; human caring; health care exploitation; culturally sensitive health care The Amish community is a unique culture. As a group the members are religious, hard-working persons who value humility and focus their lives on maintaining family and com- munity values. The Amish have many health care issues and needs. They strive to take care of their own; however, they will seek help from the outside world when necessary (Banks & Benchot, 2001). Their culture has many differences from oth- ers living in the United States. It is vital for health care profes- sionals to respect these differences when dealing with Amish individuals. Nurse practitioners can play a vital role in caring for the Amish community by providing education on disease prevention, health care maintenance, and avoidance of quack- ery medicine. The Amish have continued to live simple lives with minimal technology in an ever-changing world around them. It is important to look into their culture and appreciate some of the aspects that have continued to thrive and grow despite these changes. The following is a case study that allows a glimpse into the Amish world. CASE STUDY On a cold, snowy, windy morning in January, a phone call was received from an Amish family asking for assistance for their mother. Mrs. T., a 93-year-old Amish woman was diag- nosed with congestive heart failure (CHF) 6 months ago. Prior to her symptoms of heart failure she had been healthy without chronic health problems, routine medications, and had never been hospitalized. Mrs. T’s son stated she was not 139 Authors’ Note: This case study occurred during a clinical rotation at a rural family practice office that served a large Amish population. The authors de- veloped the article for a class assignment for a family nurse practitioner clini- cal course at Frances Payne Bolton School of Nursing at Case Western Reserve University. Journal of Transcultural Nursing, Vol. 14 No. 2, April 2003 139-145 DOI: 10.1177/1043659602250639 © 2003 Sage Publications CLINICAL PRACTICE DEPARTMENT by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com resting at night. She had been awake, anxious, and short of breath last night. Mrs. T. had been taking digoxin (Lanoxin) and furosemide (Lasix) for the past 6 months. A prescription was called to the pharmacy in town for alprazolam (Xanax). The prescription was picked up and taken to the family. In this small, rural town with a fairly large Amish population there is an understanding among shop owners and the Amish, which allowed for the prescription to be charged to the family. We drove the 5 miles to the home in a Ford Bronco in approximately 8 to 10 minutes. The horse and buggy ride to town would have taken half an hour for Mrs. T and her family. Mrs. T would have been most uncomfortable. Along the way we passed an Amish school, the children were sled riding down a large hill in front of their school. The roads to the home were narrow, winding, and composed of chip and seal. On arrival to the home, we pulled into the gravel drive and parked next to the hitching post. The driveways are usually circular so the horse and buggy do not have to back up. The house was a one-story, white ranch. There was no electric line going to the home. We entered the home through the back door; wooden steps led to the kitchen. The home was very neat, warm, and welcoming. A pie was cooling on the kitchen counter; the smell permeated the home. The hardwood floors were covered with rugs. Decoration was sparse and what was present was of a religious nature. There were no electric plugs or light switches. The lights on the walls were kerosene lamps. Mrs. T’s son and daughter greeted us and answered our questions about her condition. Her activity had declined over the past 4 weeks. They were providing assistance with all her activities of daily living. Mrs. T’s daughter is the teacher at the school we passed. She has taken the past 3 days off to help care for her mother. Another woman from the Amish church is covering for her at the school. Mrs. T and her family had decided they wanted no heroic measures to prolong her life. They only wanted to provide comfort care. Over the past 3 days her food intake had decreased; she was taking intermittent sips of liquids. Her uri- nation had decreased despite the furosemide. Mrs. T was lying on the sofa in the living room. She was sitting at an 85 degree angle, supported by three pillows. Although she was frail looking, her white hair was neatly combed into a bun. She was wearing a crisp, white, cotton nightgown. Her legs were covered with an afghan embroi- dered with the religious poem, “Footsteps in the Sand.” A small table was beside the couch; it contained a teacup and saucer. Mrs. T was sleeping; her breathing was labored and irregu- lar with Cheyne-Stokes respirations. She aroused to verbal and tactile stimulation. Despite being hard of hearing, she answered our questions appropriately. Her pale skin was cool and dry with no rashes or lesions. Her lips were moist and she displayed no sign of dehydration. Her assessment was consis- tent with CHF. Crackles were auscultated bilaterally in her lungs an S3 gallop was audible. Her bowel sounds were hypoactive. Peripheral +1 pitting edema was noted in both lower extremities and her nail beds were slightly cyanotic. We explained the purpose and use of the new medication to the family and offered oxygen as an additional comfort mea- sure. At this point the family did not feel the oxygen was nec- essary. A return visit was planned in 3 days and the family was encouraged to contact the office if they needed anything in the mean time. As we left the house, the family’s horse was wait- ing at the fence next to the driveway watching us leave, as if sensing something was going on. LITERATURE REVIEW There is a wide variety of literature pertaining to the Amish community. Some articles focus primarily on specific disease processes that are prevalent throughout the Amish population; however, multiple articles were found detailing an overall view of the Amish lifestyle, beliefs, culture, and views on childbirth and death. In addition, books have also been written about the Amish community. It is first important to understand the background of the Amish population. The Amish are a branch of Christianity that began in Europe soon after the Protestant Reformation. A new group of believers around Zurich, Switzerland did not believe in government sponsorship of religion or infant bap- tism. They felt it was contrary to the teachings of Christ in the New Testament (Kreps, Donnermeyer, & Kreps, 1997). It was believed that baptism should be reserved for consenting adults (O’Neil, 1997). Led by Ulrich Zwingli, the formal break came on January 21, 1525, when the protestors symbol- ically rebaptized themselves (Brewer & Bonalumi, 1995). Anabaptist means to be rebaptized and this was the original name given to the group. The group later split over differ- ences of Anabaptist beliefs and laxity of practices (Kreps et al., 1997). The separation from Zwingli led to the formation of the Mennonites, who are found throughout the world today, including Pennsylvania (Brewer & Bonalumi, 1995). Followers of a more conservative group led by Jacob Ammann, who separated from the Mennonite church, came to be known as the Amish (Beachy, Hershberger, Davidhizar, & Giger, 1997). Many of the Amish, today, consider themselves cousins of the Mennonites (Brewer & Bonalumi, 1995). The first record of Amish immigration to America was in 1737, the settlements were in Berks and Lancaster counties of Pennsylvania (Kreps et al., 1997). There is no Amish commu- nity remaining in Europe, today. Amish groups who remained in Europe suffered through conditions of persecution and financial hardships during the 18th and 19th centuries. Even- tually, the Amish that stayed behind converted to local Men- nonite and various Protestant denominations (Kreps et al., 1997). Pennsylvania has the greatest number of settlements, but Ohio has the largest population of Amish. The largest set- 140 JOURNAL OF TRANSCULTURAL NURSING / April 2003 by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com tlement of Amish is in a five-county area in Ohio known as the Holmes County and vicinity settlement area (Kreps et al., 1997). The Amish follow five basic tenets: adult baptism, separa- tion of church and state, ex-communication from the church for those who break moral law, living life in accordance to the teachings of Christ, and refusal to bear arms, take oaths, or hold political office (Andreoli & Miller, 1998). Historically, Amish have been farmers. “They refer to the Old Testament passage from Genesis when God commanded Adam and Eve to ‘dress’ and cultivate the garden” (Kreps et al., 1997, p. 3). In some areas, about one in three Amish breadwinners primarily make their living from agriculture (Kreps et al., 1997). Even in Amish families where the bread- winner works in a factory, the woman of the house maintains a garden. The Amish live in rural areas surrounded by farmland (Brewer & Bonalumi, 1995). The Amish live by a code of conduct that forms their behavior, speech, and manner of dressing (Banks & Benchot, 2001). According to Kreps et al. (1997), the Ordnung (ott- nuing) is a set of rules and regulations for living the Amish faith. It is largely oral, with only a few parts written down. It is what distinguishes between those in fellowship with the Amish faith and all others. The Amish are organized into church districts, each composed of several dozen families headed by a group of elders, including a bishop, two minis- ters, and one deacon. Church leaders have no formal training or qualifications. They are nominated by the group based on their upholding of the Amish beliefs. A piece of paper with a biblical quote is placed in a hymnbook. The nominees chose one of the hymnbooks. The one choosing the hymnbook with the piece of paper is considered chosen by God. Each church district has its own diverse Ordnung. “The Amish are like the quilts they make, each patch may be different, but the Amish are sewn together by their common history and religious val- ues” (Kreps et al., 1997). Two additional terms that are important in the Amish com- munity are Meidung and Gelassenheit. Meidung (mide-ung), or shunning, means cutting off fellowship with and avoiding former members who have been excommunicated, that is, told to leave the Amish faith due to serious acts against the Ordnung. Only baptized adults are subject to the Meidung. Shunning is considered the last resort. Fellowship can be restored, however, if the person sincerely repents (Kreps et al., 1997). Gelassenheit (gay las en hite) means yielding to God’s authority. This, also, helps guide Amish behavior. It is the belief in living a simple life and giving thanks to God for their blessings. Amish school children are taught the favorite motto of “JOY”: J stands for Jesus who comes first, O is for others that are second, and finally Y stands for you that should come last (Andreoli & Miller, 1998). The Amish avoid abu- sive, violent, and threatening words due to the belief that words can cause harm and disharmony (Banks & Benchot, 2001; Kreps et al., 1997). ASPECTS OF THE AMISH CULTURE The Amish are a diverse society with many traditions. They are changing all the time and have always changed to accommodate the challenges in the world around them. There are many unique characteristics that set the Amish commu- nity apart from others living in the United States. First, they believe in living simply. One example of this is that electricity is not permitted in their homes and the use of electricity from public power lines is discouraged even outside the home. Some compromises have been made, however. Batteries and large diesel engines can be used to cool milk tanks and oper- ate workshops (Kreps et al., 1997). Also, if an ill family mem- ber needs to use electricity they have to get permission from the elders. Another example of the simple living that the Amish popu- lation follow is their dress. According to Brewer and Bonalumi (1995), their plain style of dress is to reject worldli- ness, vanity, and materialism. Traditionally, men’s wear in the Amish community includes button-front trousers with sus- penders and a black felt hat in the winter and a straw wide- brimmed hat in the summer. Men shave until marriage and then grow a beard. The upper lip is always clean because church law forbids mustaches. Women, who hand-make most of the clothing, wear solid colored dresses in blue, green, gray, purple, or wine along with a white organdy head cover- ing. A black bonnet is placed over the white covering when outdoors. Black dresses are, also, worn for religious occa- sions. Some communities use straight pins to fasten the bod- ice of their dresses and secure their head covering. The use of hooks and eyes versus snaps and buttons for construction of clothing varies by each community’s Ordnung (Beachy et al., 1997). The Amish formal education system includes grades one through eight, taught by one or two Amish teachers who are picked by the school board. The school board is made up of parents of the Amish children. Teachers do not have formal education beyond the eighth grade and are not required to have certification. They are selected by the school board based on their ability to uphold and teach Amish values to the children. Children attend school from September until the end of April, Monday through Friday. Their only vacation days are usually Thanksgiving and Christmas. Subjects con- sist of spelling, phonics, reading, vocabulary, English, geog- raphy, arithmetic, penmanship, and Bible lessons. Children are required to take both English and German (Kreps et al., 1997). Amish parents pay approximately $1,000 in tuition fees annually regardless of the number of children attending school (Kreps et al., 1997). Most Amish parents refuse to send their children to high school in fear that non-Amish chil- dren and advanced education will alter their thinking and Weyer et al. / A LOOK INTO THE AMISH CULTURE 141 by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com behavior in ways inconsistent with Amish beliefs. Some uni- versities offer vocational classes and workshops for the Amish. Some of the topics are farming, milk production, cul- tivation, buggy safety, and sawmill production (Kreps et al., 1997). As mentioned previously, most Amish are farmers. Some, however, do work as laborers, carpenters, carriage makers, and other craftsmen. The Amish prefer not to work for outsid- ers, but rather on family-owned farms and businesses. Amish families can often be found selling homemade food or quilts at their homes or in nearby markets (Brewer & Bonalumi, 1995). Children are often working full-time at home or in a nearby shop by age 14 because school is completed by eighth grade (Kreps et al., 1997). According to Brewer and Bonalumi (1995), the Amish population speaks a mixture of German, English, and Penn- sylvania Dutch. Children do not learn English until they attend school and speak Pennsylvania Dutch in the home. “In Amish society, the Pennsylvania Dutch dialect is the lan- guage of work, family, friendship, play and intimacy” (Kreps et al., 1997, p. 12). The Amish also refer to the non-Amish community as “English” because that is the language used by others around them (Beachy et al., 1997). A characteristic that distinguishes the Amish from many other denominations is that they conduct their church service in members’ homes. Families in the community rotate ser- vices from one home to another, which means that 200 or more people may attend at one time. Services begin about 9:00 a.m. and last about three and one half hours. A meal, pre- pared by the host family, follows the service along with talk and visiting among the guests until afternoon chore time (Kreps et al., 1997). Meetings usually take place twice a month and scriptures from the Bible are read. The Amish dis- courage boasting of their Bible learning and intimidation of others with Bible quotes (O’Neil, 1997). They also believe that “those who worship God, obey the church, provide for family and community will enjoy salvation” (O’Neil, 1997, p. 1133). The majority of the Amish live in a household with six or more persons that often include extended family members. It is common for aunts, uncles, and cousins to live across the road or on the farm next door. A dawdy haus, which is right next to or often attached to the original house, is where elderly parents move when they “retire,” and the larger house is given to the youngest of their children. In Amish society, the elderly are considered important sources of information for the youn- ger generation. They give advice on topics that include health and illness, household chores, cooking, gardening, farming, and predicting the weather (Kreps et al., 1997). The Amish do not believe in retirement homes; instead, they reside at home where they are cared for by their family (Palmer, 1992). The average age of death in the Amish population is approxi- mately 71 years old (Mitchell et al., 2001). The Amish also believe in taking care of their young, therefore there are no day care centers. The Amish community thinks they are responsible for the young, elderly, and the sick. The daily life of the Amish is centered on the home. Children, often born at home, play at home and attend a school that is within easy walking distance. Many Amish individuals work full-time in the home. Recreational activi- ties take place at home or with nearby neighbors. Church ser- vices and marriage ceremonies are held at the home. Most meals are prepared and eaten at home. Social gatherings and clothing making are also performed at home. Finally, retire- ment occurs at home as well as end-of-life care and the funeral service (Kreps et al., 1997). Life almost always begins and ends in the Amish home. Members of the Amish community do not practice divorce or birth control. Therefore, large families are encouraged. The average Amish family has six children (O’Neil, 1997). They also tend to socialize with and marry their own. Inter- marriages are very common among the Amish and the major- ity of couples who marry are usually related to each other in some way (McKusick, 1980). This puts the Amish population at risk for a high incidence of genetic diseases. Recessive genetic disorders are increased among the Amish (McKusick, 1980). Finally, the Amish view death as a natural part of life. They believe in eternal life. Death is seen as “God’s will” and the Amish often take their loved ones home to die rather than have death occur in a hospital setting (Banks & Benchot, 2001). When an individual in the Amish community dies, friends and families gather at the home as soon as they receive word of the death. Family members of the same gender dress the body for burial. Men are dressed in a white shirt, vest, and pants and women are dressed in white with a white cape and apron. The coffin is wide at the head and narrows at the feet and is void of ornamentation (Palmer, 1992). Amish members of the community outside the family prepare the grave. The person is then buried in an Amish cemetery (Girod, 2002). The leading causes of death in the Amish are heart disease and accidents and most men outlive the women (Palmer, 1992). Genetic diseases can also have a big impact on life expectancy and chronic health conditions. EFFECTS ON HEALTH CARE DECISIONS There are many factors that affect the health care of the Amish population (see Table 1). The Amish brought with them from the old country many home remedies and folk medicine. Some Amish still practice Powwowing; also know as braucha or braucheri, which is an Old World brand of faith healing. The belief holds that certain people inherit the power to heal by touch, or moving around a sick person, or through audible or silent incantations (Adams & Loverland, 1986). The Amish are often preyed upon by quackery fraud and med- ical exploitation. 142 JOURNAL OF TRANSCULTURAL NURSING / April 2003 by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com Modern health quacks are expert salesmen. They use sci- entific terms and many who target the Amish quote Bible scriptures. The Amish cultural belief in rural living and rigor- ous physical labor as a means to good health makes “natural” treatments attractive. The quacks will use convincing testi- monials from Amish community members to spread the word of their cure. Many dishonest salesmen will discredit the medical establishment by claiming a massive conspiracy by licensed health care providers, drug companies, and medical associations. The Budget, an Amish newspaper written by correspondents from Amish communities in North and South America is published in Sugarcreek, Ohio. It contains news, announcements of births, deaths, and marriages as well as a number of advertisements for questionable alternative health products and services (Palmer, 1992). Types of health fraud popular among the Amish include chelation therapy, radon mines, Tijuana clinics, medical devices, and herbal supplements. Chelation therapy is a series of intravenous infusions containing disodium Ethylene- Diamine-Tetra-Acetic acid (EDTA) and is approved for hypercalcemia and heavy metal poisoning (Sampson, 1997). Some Amish seek chelation therapy for atherosclerosis and neutralization of free radicals. Chelation therapy can cause hypotension, shock, acute renal failure, and sudden cardiac death from hypocalcemia, however, and has been shown to have no effect on atherosclerosis or reduction in free radicals (Sampson, 1997). Also, many Amish often visit abandoned mines and pay to purposely expose themselves to radon gas in the belief that it will cure arthritis, asthma, migraines, diabe- tes, and other ailments. Radon gas is blamed for many lung cancer deaths (Cannon, 1996). Many clinics found in Tijuana, Mexico offer treatments appealing to the Amish such as cof- fee enemas, goat blood therapy, and the healing power of cow embryos. Some clinics also offer discounted surgeries includ- ing hip replacement and hysterectomy (Barrett, 2001). Finally, the Amish use herbal remedies. Often herbal tablets, garlic, and vitamins are their self-prescribed first-line treat- ment against illness and injury (McCollum, 1996). They believe strongly that vitamins and health foods are significant in maintaining one’s health and will often pay expensive herbal remedy prices (Palmer, 1992). The functional ability to work, as well as the attitude of wanting to work, is important in the Amish perception of health. Significant disability, such as blindness or inability to walk, does not inhibit productivity. The Amish primarily work as a team; therefore a person with a disability can per- form tasks that are contributory yet less physically demand- ing (Hewner, 1998). These may include duties such as clean- ing vegetables or cutting scraps for rugs. Disability, therefore, is minimized in large Amish households. As mentioned ear- lier, the elderly live with their adult children, a practice that places less emphasis on individual function and more empha- sis on group function. Independent function is much less important in Amish culture than among the non-Amish (Hewner, 1998). The Amish population will seek out Westernized medical care and technology when necessary. The Amish are not pro- hibited by church law from taking medication or seeking care from a doctor, however, as discussed earlier, they will often use other remedies first (Girod, 2002). The Amish define ill- ness as a failure to function in the work role instead of in terms of symptoms. For this reason, they may be more likely to seek care for acute traumatic conditions as opposed to chronic ill- nesses (Palmer, 1992). When the Amish do seek medical attention, they often have severe symptoms and increased risk of mortality secondary to delay in seeking care. The Amish often do not practice preventative medicine, as well. This is partly due to a lack of education and understanding of micro- organisms and disease. Many Amish also believe that sins cause illness. If sins are the cause of illness, “they believe, then no amount of prevention or immunization will prevent illness, and there is no need to participate in preventive pro- grams” (Adams & Leverland, 1986, p. 63). This is an area that nurse practitioners can work closely with the Amish and play a vital role in education. EFFECTS ON ACCESS TO CARE There are several factors that affect the Amish’s access to health care. Transportation is one factor. The horse and buggy is a distinct symbol of Amish religious values and unique life- style. A medical appointment may be missed due to a horse that will not leave the barnyard (McGinn, 1996). The horse and buggy can usually travel about 10 miles an hour, so the Amish tend to live relatively close to their Amish neighbors in Weyer et al. / A LOOK INTO THE AMISH CULTURE 143 TABLE 1 Reasons for Medical Exploitation of the Amish Education The Amish only attend school through the eighth grade. They have a limited background in math and science. The Amish do not use the Internet or other electronic sources of information. Insurance Many Amish do not have health insurance and mainstream medicine is too expensive. Money The Amish are cash paying customers who pay their bills in a timely manner. Distrust Many Amish distrust mainstream medicine. Some may have had a bad experience with doctors or hospitals. Pacifism The Amish are forbidden by their religious beliefs from suing. They rarely alert authorities. Culture The Amish have a strong cultural belief in folk medicine and home remedies. SOURCE: Data from Adams and Loverland (1986). by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com order to visit others in their community regularly and attend church services (Kreps et al., 1997). This may make travel to health care facilities and hospitals a difficult task. Many of the facilities are often located outside of their rural setting. Traveling in bad weather is also another obstacle. Transporta- tion by car or van from an “English” neighbor or friend is arranged for long distance travel or when traveling in larger groups. The majority of the Amish do not have telephones in their homes, which affects access to immediate care particu- larly in times of emergency. The Amish usually have to use a public phone or travel to a neighbor’s house to use a phone. EFFECTS ON REIMBURSEMENT OR PAYMENT OF SERVICES Health care can be costly to the Amish population, because they are self-pay clients who do not use commercial health insurance. The Amish believe that they are responsible for their own group (Dickinson, Slesinger, & Raftery, 1996). Communities form their own type of insurance fund in which Amish individuals contribute an initial amount and then again when someone has a need (Brewer & Bonalumi, 1995). This contribution is called “Church Aid” or “Amish Aid.” If an Amish person incurs an unmanageable expense, the Amish community will step forward and help with medical pay- ments or money for repairs (Beachy et al., 1997; Palmer, 1992). Therefore, it is easy to see how medical payments can be trying on the Amish community and how many often pro- long medical attention for what they believe may be minor ill- nesses or injuries. In many situations, however, delays in seeking treatment increase medical expenses (McCollum, 1996). IMPLICATION FOR PRACTICE Nurse practitioners, with physician collaboration, can play a vital role in the care of the Amish. Nurse practitioners specializing in family medicine and midwifery may provide an excellent source of care for this population because of the family and community needs in a rural setting. There are often fewer physicians in these settings, opening the door for nurse practitioners. Nurse practitioners can remind their Amish patients that there is no religious rule prohibiting immunizations against disease, and can use education to combat superstition and promote disease prevention (Adams & Leverland, 1986). Education can be very vital in helping the Amish avoid quackery medicine. Nurse practitioners can play a big part through education in preventing the Amish from getting caught up in scams and ineffective health treatments. Acceptance of the Amish for who they are will help in the development of a trusting relationship. According to Watson (n.d., p. 5; see also, McGraw, 2002), developing and sustain- ing a helping-trusting, authentic, caring relationship is one of the necessary steps in providing human caring; she describes this as the essence of nursing practice. Human caring is actualized in the moment based on the actions and choices made by both the one-caring and the one- being cared for . . . the goal in the relationship is the protec- tion, enhancement, and preservation of patient dignity, humanity, wholeness, and inner harmony. (McGraw, 2002, p. 104) Nurse practitioners should take the time to understand the different beliefs of the Amish to provide the best care possible (Adams & Leverland, 1986). “They must be acutely aware of their own cultural biases, especially when those may be at odds with the Amish orientation” (Wiggins, 1983, p. 28). The best approach that the nurse practitioner can take with the Amish is to talk simply and honestly with them. They are not impressed with increased education and are disinterested in individuals who act arrogantly or are bossy (Beachy et al., 1997). Nurse practitioners can reinforce an Amish person’s health care practices, such as the use of creams and supple- ments, as long as it is not detrimental to his or her health (Palmer, 1992). However, they may also want to offer the bio- medical perspective for consideration and develop a mutually agreed on plan of care. Promoting mutual understanding and respect is always better than encouraging intolerance because intolerance leads to conflict (Kreps et al., 1997). This article has discussed the Amish culture and its rela- tionship to medical care. It has given us a look into a culture that continues to thrive with simple surroundings, despite the advances in technology and daily changes in the world. The Amish have continued to maintain their faith, values, and strong sense of family and community. They have not allowed outside influences to penetrate their beliefs or alter their cul- ture. If we continue to look closely at the Amish community, perhaps they can teach us some valuable lessons in life. As Mrs. T was peacefully dying at home, surrounded by her friends and family, she was comfortable in her own surround- ings. She was not in a foreign place being cared for by strang- ers or being monitored by technology. She was dying in her home, with her family, in her community. It is easy for us to get caught up in our society with all the increased technology and medical advances, but perhaps we have lost some impor- tant things along the way. We may have lost sight of some valuable qualities that the Amish can help us regain, if we let them. A quote from an Amish man in the 1993, summer issue of the Small Farm Journal (as cited in Kreps et al. 1997) sum- marizes some of what we can learn from the Amish. We realize that not everyone is cut out to be one of the plain people. Many have not the opportunity, but here is the chal- lenge. If you admire our faith—strengthen yours. If you admire our sense of commitment—deepen yours. If you admire our community spirit, build your own. If you admire 144 JOURNAL OF TRANSCULTURAL NURSING / April 2003 by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com the simple life—cut back. If you admire deep character and enduring values, live them yourself. (p. iv) REFERENCES Adams, C. E., & Leverland, M. B. (1986). The effects of religious beliefs on the health care practices of the Amish. Nurse Practitioner, 11(3), 58, 63, 67. Andreoli, E. M., & Miller, J. S. (1998). Aging in the Amish community. Nursing Connections, 11(3), 5-11. Banks, M. J., & Benchot, R. J. (2001). Unique aspects of nursing care for Amish children. American Journal of Maternal Child Nursing, 26(4), 192-196. Barrett, S. (2001). Quackwatch. Retrieved May 25, 2001 from http:// www.quackwatch.com/ Beachy, A., Hershberger, E., Davidhizar, R., & Giger, J. N. (1997). Cultural implications for nursing care of the Amish. Journal of Cultural Diversity, 4(4), 118-126. Brewer, J. A., & Bonalumi, N. M. (1995). Cultural diversity in the emergency department. Journal of Emergency Nursing, 21(6), 494-497. Cannon, S. (1996). Plain prey. Old mines yielding new bonanza: Radioactive gas. Retrieved April 29, 2001, from http://www.kcstar.com/plain/stories/ mine22.htm Dickinson, N., Slesinger, D. & Raftery, P. (1996). A comparison of the per- ceived health needs of Amish and non-Amish families in Cashton, Wisc. Wisconsin Medical Journal, 95(3), 151-156. Girod, J. (2002). A sustainable medicine: Lessons from the old order Amish. Journal of Medical Humanities, 23(1), 31-42. Hewner, S. J. (1998). Fertility, migration, and mortality in an old order Amish community. American Journal of Human Biology, 10, 619-628. Kreps, G. M., Donnermeyer, J. F., & Kreps, M. W. (1997). A quiet moment in time: A contemporary view of Amish Society. Sugarcreek: Carlisle Press. McCollum, C. (1996). Physicians’ perspectives on treating Amish patients. Wisconsin Medical Journal, 95(3), 157-161. McGinn, K. (1996). Debbie LaBerge: Caring for Amish and Mennonite fam- ilies. Nurse Practitioner Forum, 7(2), 56-57. McGraw, M. J. (2002). Watson’s philosophy in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization and appli- cation (pp. 97-121). St. Louis, MO: Mosby. McKusick, V. A. (1980). The Amish. Endeavour, 4(2), 52-27. Mitchell, B. D., Hsueh, W., King, T. M., Pollin, T. I., Sorkin, J., Agarwala, R., et al. (2001). Heritability of life span in the old order Amish. American Journal of Medical Genetics, 102, 346-352. O’Neil, D. J. (1997). Explaining the Amish. International Journal of Social Economics, 24(10), 1132-1139. Palmer, C. V. (1992). The health beliefs and practices of an Old Order Amish family. Journal of the American Academy of Nurse Practitioners, 4(3), 117-122. Sampson, W. (1997, Fall/Winter). The pharmacology of chelation therapy. Scientific Review of Alternative Medicine. Retrieved June 6, 2001 from: http://www.quackwatch.com/ Watson, J. (n.d.). Watson’s caring theory. Retrieved October 5, 2002, from: http//www2.uchsc.edu/son/caring/content/wct.asp Wiggins, L. R. (1983). Health and illness beliefs and practices among the old older Amish. Health Values: Achieving High Level Wellness, 7(6), 24-29. Sharon M. Weyer, MSN, RN, NP-C, is a research nurse in the de- partment of Family Medicine, Research Division at Case Western Reserve University and a family nurse practitioner at the Viola Startzman Free Clinic in Wooster, Ohio. Her research, teaching, and clinical interests include health promotion/disease prevention and access to health care for the uninsured. Victoria R. Hustey, MSN, APRN, BC, is a registered nurse in the Department of Pediatric Intensive Care at University Hospitals of Cleveland, Rainbow Babies and Children’s Hospital, and pediatric clinical instructor at Kent State Univeristy, Ashtabula. Her clinical interests include family nurse practitioning. Lesley Rathbun, MSN, RN, CNM, is an obstetrical staff nurse in the department of nursing at Middlefield Care Center—Amish Birthing Center. Her clinical interests include midwifery and family practice. She is a master’s student in midwifery and family nurse practitioner at Case Western Reserve University, Frances Payne Bolton School of Nursing. Vickie L. Armstrong, MSN, RN, is a clinical nurse in the De- partment of Medical/Surgical Nursing at University Hospitals of Cleveland. Her clinical interests include geriatrics. She is currently a master’s student in the Gerontological Nurse Practitioner Pro- gram. She also serves on the clinical faculty for Case Western Re- serve University, Frances Payne Bolton School of Nursing. Samantha Reed Anna, MSN, RN, is a staff nurse in the postanesthesia care unit at the Cleveland Clinic Foundation. Her teaching interests include undergraduate clinical education. She is currently a master’s student in the Family Nurse Practitioner Pro- gram at Case Western Reserve University. She also serves on the clinical faculty at the Frances Payne Bolton School of Nursing. Jeanne Ronyak, MSN, RN, is a clinical nurse in the family birth center at St. Francis Health Center. Her clinical interests include maternal and child health nursing and family nurse practitioning. Carol Savrin, ND, CPNP, FNP-C, is an assistant professor in the Department of Nursing at Case Western Reserve University. Her re- search interests include cardiovascular risk factors in adolescents. She is also lead faculty in the pediatric and family nurse practitioner programs at Case Western Reserve University. Weyer et al. / A LOOK INTO THE AMISH CULTURE 145 by Books Editorial on January 3, 2010 http://tcn.sagepub.comDownloaded from http://tcn.sagepub.com