Cultural Competencies for Healthcare Providers Working with Rural Finnish Americans

By Abigail K. Carlson
2021, Vol. 13 No. 01 | pg. 1/1

Abstract

The number of Americans aged 65-years-and-older is projected to increase significantly by 2050. As rural older adults age-in-place, it is imperative to examine the links between cultural competencies, ethnic minority status, and access to care. Rural providers from outside the local culture must recognize the need to practice cultural humility and cultural sensitivity to champion best practices of care. Finnish Americans have a unique subculture in the Upper Midwest, particularly in the Upper Peninsula of Michigan, where they have historically faced much hardship, as well as significant barriers and limitations to accessibility, availability, and affordability, of healthcare services. These challenges and barriers to care include high rates of socioeconomic hardship, homelessness and substance use. This article provides information on history and cultural norms of Finnish Americans to serve as a historical log and to improve communication between residents and providers to ensure best practices and subsequently, quality of life.

The United States is home to a rapidly aging population. Between 2012 and 2050, the number of adults aged 65-and-older is projected to double (Ortman, Velkhoff, & Hogan, 2014). Unfortunately, the healthcare industry faces several challenges, such as nursing shortages, staff burnout, and the high cost of medical care (Owens, 2018). Rural hospitals and clinics also typically receive less funding and face greater staffing shortages than urban locations, which increases the health risks for residents compared to their urban counterparts (Bailey, 2009). Disparities and gaps in healthcare related to accessibility, affordability, and availability of services will continue to increase, until the income inequality gap is addressed. Although professional healthcare programs train medical providers in rural cultural competencies, specific ethnic groups have greater health risks than the general population due to several remaining, unaddressed needs.

The U.S. Census Bureau classifies three types of geographic areas based on population. There are the two types of urban areas: (1) urban clusters (UC) which are communities with a population of 2,500-50,000 and, (2) urbanized areas (UA) or geographic regions with a population of 50,000 or greater (U.S. Census, 2020). In contrast, a rural area is less specifically defined as an area that encompasses “any population, housing, or territory” not included in an urban area (U.S. Census, 2020).

As Americans age-in-place, older adults face geographic, social, emotional, and financial barriers to the accessibility and availability of healthcare services (Brenes, et al., 2015). Older adults in rural areas face significantly greater challenges in access to care than their urban counterparts. Unfortunately, since rural adults face additional issues with affordability and availability of services, this creates potential for increased health risks due to limitations in the access to care (Brenes, et al., 2015).

American rural culture has traditionally upheld the values of self-reliance, pride in working-class status, and reliance on family and community (Bushy, 2009; Taramaa, 2009). According to a study by Skoufalos et al. (2007), older adults in rural areas consistently reported a greater sense of pride in community, as well as feelings of safety and security in contrast to urban counterparts. However, geographic isolation is inevitable in some locations and older age increases the opportunity for social isolation. Both of these factors decrease access to care (Elder & Retrum, 2012). Social isolation can be imposed by: (1) the act of an individual physically and socially choosing to distance himself from social support systems, and, (2) the individual’s perceived loneliness, which can also cause negative psychological effects (Elder & Retrum, 2012).

In this paper, ethnic minority is defined as a subpopulation that is not politically governing, and also is considered to be an ethnic group, which is a group of people that share a culture different from other groups (Arvio, 2019). According to research by Petterson et al. (2009), individuals who belong to rural minority populations face further barriers due to language and communication differences and/ or differing cultural norms. Some issues associated with minority populations include higher rates of unemployment and lack of insurance, language differences, and increased stigmas around mental health and end-of-life care (Petterson, et al., 2007). The patient-provider relationship can drastically affect patient retention rates, if the provider is not trained in cultural competencies, let alone cultural humility and cultural sensitivity (Betancourt et al., 2016). This paper discusses rurality, social stigmas, ethnic and/ or minority culture, and provider training to improve the accessibility of services and patient-provider relationships for rural elderly clientele.

Barriers to Healthcare

Self-reliance and working-class status are traditionally held values in rural culture. This has often been characterized through as the “rugged individualism” ideology and stereotype of rural Americans (Bushy, 2009; Kushnir, 2016). Although rural adults delay medical assistance compared to their urban counterparts, it does not mean that they lack treatment-seeking behavior, since they also face greater barriers to care. Unfortunately, those who attempt to access care might face additional difficulties, due to language and cultural differences with providers, who might be educated in rural cultural competencies yet lack the necessary training to address barriers with racial or ethnic minority clients.

Older adults face challenges, such as mobility loss, smaller social circles, and isolation at home (Brenes, et al., 2015; Elder & Retrum, 2012). Geographic isolation, cost of care, stigma, and lack of available resources and services are the most common barriers to care for rural residents of all ethnic backgrounds (Brenes, et al., 2015; Bushy, 2009). However, this is complicated when ethnic differences are also present. Additional barriers to care include long travel distances, lack of trust in providers, and lack of technology or public transportation (Bushy, 2009; Gale, et al., 2019).

Minority populations face greater health disparities than their white counterparts (Mckenzie & Bushy, 2004). Ethnic minority patients who belong to racial or ethnic minorities tend to trust healthcare providers with a shared heritage (Holley, 2013). Although minorities comprise 25% of the U.S. population, only one-tenth of providers are minority, and even fewer are recruited to work in rural areas (Holley, 2013).

The United States has seen an increase of racial and ethnic minorities in rural areas in the past few decades. These groups now comprise 17% of the rural population (Bushy, 2009; Mckenzie & Bushy, 2004). Minority elders face more barriers to healthcare than their white counterparts (Mckenzie & Bushy, 2004). Barriers to care include higher insurance rates, language differences, stigmas, cultural expectations, and mistrust due to discrimination that lead to a lack of treatment-seeking behavior or the termination of a patient-provider relationship (Gale, et al., 2019; Petterson, et al., 2009; Sorkin, et al., 2016). Ethnic minorities will continue to face increasingly poor health outcomes without providers who are taught to mitigate specific barriers, as the communication gap grows larger.

Studies indicate that healthcare providers trained in cultural competencies can address stigma and build trust, which improves the quality of care (Fisher-Borne, Cain,& Martin, 2015). In addition, providers who maintain awareness by practicing cultural humility and cultural sensitivity mitigate disparities and improve care for patients from racial or ethnic minority backgrounds (Bushy, 2009).

Little research has been conducted on the intersection of rural healthcare and ethnic minority elders. Studies have focused on Hispanic farm workers in Montana (Johnston & Herzig, 2006), African Americans in the Deep South, and Native American populations across the United States (Mckenzie & Bushy, 2004). While academic institutions have incorporated cultural competency training into their curriculum, additional instruction on cultural humility and cultural sensitivity would improve the patient-provider relationship.

Cultural humility and cultural sensitivity improve the quality of care for the patients and benefit providers who incorporate these concepts into practice. Cultural humility calls for providers to engage in self-reflection and self-critique as lifelong learners and reflexive practitioners (Tervalon & Murray-Garcia, 1998). Culturally sensitive providers also build better rapport with patients and families, when they tailor care to the client’s specific cultural and spiritual needs (Fang, et al., 2016). This is important for people from different cultures with specific norms and beliefs they might hold, in regard to decisions of mental health treatment or end-of-life care (Fang, et al., 2016; Garrett, et al., 2015).

This paper discusses practices that rural healthcare providers can utilize, when they treat ethnic minority elders. The discussion will focus on Finnish and Sámi Americans in the rural Upper Midwest. Finnish and Sámi Americans have lived in this region for generations. This subpopulation maintains a set of cultural norms and traditions that are unique to its history in the United States. Healthcare providers from different backgrounds who incorporate cultural competency, cultural humility, and cultural sensitivity into practice can improve the patient-provider relationships and quality of services.

Terms for Healthcare Providers

When discussing cultural competencies, this paper will utilize terminology that is outlined and defined below.

Cultural competency

It is important to consider the ethical implications of this project, in order to reduce inaccuracies, mitigate stigma and stereotypes, and uplift an indigenous ethnic minority group that has been subject to discrimination and historical trauma. When providers and patients have a shared ethnic background and/ or language, it assists in building trust, so that optimal care is achieved (Holley, 2013). Unfortunately, this is often not the case. Therefore, cultural competencies are often employed in medical training programs.

Competency training is a means to provide insight into a patient’s culturally-influenced personal experience and offers healthcare practitioners the opportunity to maintain a relevant, empathic presence through the withholding of judgment. Research by Fang et al. (2016) and colleagues shows that medical interventions have been incorporated into the educational curriculum for nursing and medical students. However, practice-based interventions are lacking and create a knowledge gap in regard to good practice in home, hospital, and hospice settings . As author Jay Katz (2002) states, “socialization of physicians reinforces the tendency [of practitioners] … to turn away from uncertainty” and conditions them to being “bearers of certainty.”

Providers must acknowledge that the complexity encompassed by a singular culture cannot be fully understood or learned through literature or coursework alone. Providers who demonstrate self-awareness can validate the patient’s cultural background and improve the quality of services. This is particularly crucial for mental health providers. Mental health providers who commit to continual intercultural communication can mitigate harmful stereotypes and bias in the client-provider relationships, when working with mentally ill and/ or elderly individuals (Pettersen, et al., 2009).

Cultural Humility

Cultural humility is a principle that requires providers to remain humble in practice. It is a mechanism of empowerment for patients and providers across the cultural divide. This paper will utilize the Hook et al.(2013) definition of cultural humility, as the “ability of a provider to maintain an interpersonal stance that is other-oriented (or open to the other), in relation to aspects of cultural identity most important to the client.” Cultural humility allows the provider to maintain awareness of his positionality within the patient-provider relationship, without minimizing the patient’s values or means of communication.

One study by Foronda et al. (2015) found that the benefits of providers who practice cultural humility include respect, optimal care, mutual empowerment, partnerships, and lifelong learning. Optimal care was achieved through greater understanding, effective decision-making, quality of life, and communication (Foronda, et al., 2015). Another benefit of cultural humility is the commitment of providers to lifelong learning, which includes the process of transformation, commitment to self-evaluation, and finally self-critique through reflection, self-reflection, and reflectivity (Foronda, et al., 2015; Tervalon & Murray-Garcia, 1998). The capacity of providers who engage in both reflective practice and mutual empowerment permits continual growth and encourages a positive experience for clients to continue to return and develop relationships with their practitioners.

Cultural sensitivity

Cultural sensitivity pertains to the demonstration of respect and conscientiousness by providers for the unique cultural and spiritual needs of patients from diverse backgrounds. According to Tucker et al. (2011), culturally sensitive care “(1) displays patient-desired, modifiable provider and staff behaviors and attitudes, (2) conceptualizes the patient-provider relationship as a partnership that emerges from patient-centeredness, and (3) is patient empowerment-oriented” . Culturally sensitive providers can reduce embarrassment of patients from cultural or ethnic groups who stereotype symptoms and might otherwise attempt to minimize illness and/ or not seek care when it is needed (Bushy, 2009). Providers who are culturally sensitive become more response able; that is, those who use it in practice gain the “ability to respond in a reasonable way for self and others,” which in turn feeds back into a healthy patient-provider relationship (Berry, 2015).

Health Barriers for Older Adults

There are a great number of barriers to the provision of healthcare services for the growing proportion of American aged 65-years-and-older. For urban and rural adults, barriers to care can include the cost of care, lack of transportation, and stigma and/ or stereotyping due to cultural norms. Older adults who live in rural areas face a greater number of barriers to healthcare services, when compared to those faced by their urban counterparts. The effect of rurality on healthcare systems creates a fragile juxtaposition for those who want to acquire care but who also live in an area where the culture might create harmful stereotypes that reduce treatment-seeking behavior and increase the opportunity for isolation.

Older adults face smaller social circles, bereavement, and reduced mobility (Longwell & Waite, 2009). These pose significant barriers to care. Any further barriers complicate mental and physical health issues and also put this population at greater health risk. Rural residents face a greater likelihood of these events, as well as other barriers that increase health risks for older adults, such as isolation. Isolation and other barriers to care reduce the chances of older adults receiving medical care.

Older adults typically have smaller social circles, which increases their opportunity for social isolation (Bacsu, et al., 2012). In addition, poor health and bereavement issues provide additional reasons for older adults to isolate themselves within their own homes (Blix & Hamran, 2017; Longwell & Waite, 2009). This is of particular concern for older women, who increasingly self-isolate within their homes as they age compared to men, and who also tend to live longer (Shankar, et al., 2011). Older adults engaged in wider social networks are more likely to experience positive health impacts, according to Bacsu et al. (2012).

In addition to social isolation, geographic isolation separates patients from medical care due to distance, geographic barriers, or both (Bushy, 2009). Rural older adults are at even greater risk, due to a lack of transportation and an increased likelihood of chronic illness (Bushy, 2009; Gale, et al., 2019). Geographic barriers include landforms or bodies of water. The distances required to drive around barriers add extra time for transportation to services, which increases health risks (Bushy, 2009).

The cost of transportation can hinder treatment-seeking behavior for rural older adults. This behavior is also influenced by the actual cost of care. The high cost of healthcare services, coupled with a lack of insurance, can deter older adults from seeking medical care. This is due to fewer options for earning income and results in increased financial hardship, which can result from rurality and/or other issues, such as immigration status (Bailey, 2009). Residents of rural areas tend to have lower incomes than their urban counterparts, according to research by Bacsu et al. (2012). Rural older adults also tend to have lower insurance rates than urban counterparts. This is even more notable for those who belong to ethnic minorities (Bacsu, et al. 2012; Petterson, et al., 2009).

Ethnic minority elders are at an increased risk of being uninsured, due to communication barriers and cultural norms. Cultural expectations to take care of elderly family members in some ethnic minority groups can also prevent rural older adults from getting the healthcare they need. For older Finnish Americans, relationships with kin become more important, since they focus less on services from non-kin, which are preferably provided through home care. This can unfortunately be costly and deter some individuals from seeking treatment. For those who rely on home care, it can also delay access to emergency services or establishing relationships with doctors whom they must see in-person.

In old age, rural adults face a greater risk for social isolation, due to mobility loss, smaller social circles, and bereavement (Longwell & Waite, 2009). The lack of technology and greater physical distance from family, neighbors, and communities also increases the risk for social isolation (Gale, et al., 2019). In the Upper Peninsula of Michigan, it is typical for the youth to leave the region in search of jobs (Ulrich, 2010). Since the Great Migration of Finns to the United States took place at the beginning of the 20th century, there are many third and fourth generation Finnish Americans who remain in the area (Huhta, 2014). As the area’s adults age, it is not uncommon for their older adults to invoke ethnicity and heritage as a means of providing order, meaning, and continuity to life experiences (Stoller, 1996).

The remaining older generations face an additional communication barrier that has been caused by the departure of younger, more assimilated generations who bridge a cultural and communication gap between elders and healthcare providers.

Although these factors create barriers for individuals who live in rural areas, communication and linguistic barriers due to ethnic differences in the patient-provider relationship create further difficulties in health care. When providers are not trained to respect rurality and ethnic differences, stigmas and stereotyping of mental health and older adults’ end-of-life care decisions can surmount in hospitalizations and/ or procedures that are deemed unnecessary and/ or remain unwanted, followed by costly medical bills (Petterson, et al., 2009). For Finnish Americans in the Upper Midwest, particularly the Upper Peninsula of Michigan, this situation is too often the case. It is, therefore, imperative to explore the history of Finnish Americans to better serve and understand how to bridge the cultural patient-provider relationship gap.

Although the Finnish American presence is well-known in the Upper Midwest, this population’s own history has been lost in time. The Finnish American population continues to age-in-place and elders face increasing healthcare costs. This paper will detail the history of the Finnish American population and its cultural norms as a means to mitigate health disparities. This paper also provides a historical log and discusses information on sources that have been published on this hidden population throughout its presence in the United States.

It is imperative to discuss the history of the Finnish population in order to understand the development of this unique subculture in North America, particularly in the United States. Finnish American history is closely tied to the cultural norms and immigrant experience in the mining communities of the Upper Midwest. Since Finnish history is integral to the Finnish American experience, this paper details a brief history of the home country and the immigrants who settled the United States.

History of Finns and Finnish-Americans

According to Korkiasaari and Roinila (2005), “ethnic identity is both personal and individual. It can be based on [any combination of] geography, nationality, ancestry, family, culture and subculture, religion, language, and race.” The Finns’ location between the East and the West introduced Asiatic customs, such as cupping and intermarriage with other cultures. The isolated location resulted in the development of the Finno-Ugric ethnic group that is genetically distinct (Dutton, 2014). The position and relative isolation of this country also resulted in a distinct culture and affected the development of the Finnish language (Lewis, 2011).

Finns and Sámi are Finno-Ugric peoples, who have inhabited Finland and the region around the Baltic Sea for thousands of years (Kirby, 2005). Due to the migration patterns of cultures, the Finnish language and culture are most closely related to Hungarian and Estonian, which are also Finno-Ugric, in contrast to Swedes who are Germanic (Taramaa, 2009). Although Finns and Sámi are both native and considered indigenous peoples, Finns have undergone modernization, while the Sámi have remained traditional (Beach, 2015) . The majority of the Sámi population continues to practice cultural ethnic norms and are the last remaining indigenous people of Europe (Malinen & Rushton, 2017).

Prior to modernization, Finns were hunter-gatherers, who eventually took up agriculture (Kirby, 2006; Lewis, 2005). Reindeer husbandry was integral to the lifestyle of ancient Finns, and continues in the present day (Kirby, 2006; Malinen & Rushton, 2017). The Finnish religion was originally paganistic and centered on nature worship and animism (Beach, 2015; Kirby, 2006). The Sámi people continued to practice shamanism, which died out by the 17th century due to colonization. However, it is still revered today (Beach, 2015).

In the 12th and 13th centuries, Sweden introduced Christianity and colonized the area during the Northern Crusades. It eventually incorporated Finland into the Swedish kingdom (Kirby, 2006). The region was initially overseen by a bishop. Power was transferred to Swedish nobility. The Swedish ruling class maintained their language, while the peasantry continued to speak Finnish (Grantham, 2005; Lewis, 2011). This dynamic established a hierarchy, which allowed Swedes to remain in power. As a result, Sweden continued to occupy Finland for six centuries (Kirby, 2006; Keskinen, 2019).

In 1809, the Finnish War between Sweden and Russia resulted in Russia incorporating the Grand Duchy of Finland into its empire (Kirby, 2006; Lewis, 2011). Finland gained greater autonomy through its new status. However, it did not have full independence as a nation-state (Karner, 1991). Throughout the 19th century, Finns began to develop a sense of unity and pride through nationalism. The new sense of national identity that was established during this era has been referred to as “Finnishness” (Grantham, 2005).

Despite Finland’s nationalism, however, it was still influenced by Swedish rule. As a result, there was a growing sentiment to permanently replace the Swedish language (Kirby, 2006). Although Finns spoke their native tongue for centuries prior to colonization, Finnish became a symbol of Finnishness that led many proud yet impoverished Finnish emigrants to be judged in Europe, as well as in the United States (Taramaa, 2009; Kirby, 2006). As Finland modernized along with Western Europe, Finns gradually gained international recognition as a distinct people, with their own culture and language. Unfortunately, in the latter half of the 19th century, famine occurred. As a result, Finns were forced to emigrate to the United States to escape famine, during what is known as the Great Migration (ARVIO? 2019; Holmio, 2001).

Finland’s increased sovereignty was disrupted when, in the early 20th century, Russia attempted to limit Finland’s autonomy and alter Finnic culture through a process called Russification (Kirby, 2006). Revolutions in Russia led to abdication of the throne by the tsar in 1917 and the Finnish parliament declared independence, which established the nation-state on January 4, 1918 (Lewis, 2011; Karner, 1991). However, emigration of Finland’s poorest peoples to the United States meant that a substantial number of its original inhabitants had already left by the time independence was established (Arvio, 2019). Some examples of those who migrated included young men who could not find work in city factories, second sons and their families who did not inherit the family farm, and the Sami people (Arvio, 2019; Taramaa, 2015; Holmio, 2001).

Though mainstream Finnish culture and society has modernized, the Sámi still remain traditional and continue to practice indigenous culture (Beach, 2015; Kuokkanen, 2000). Prior to colonization, in fact, many Sámi originally lived in southern Finland among the Finns but moved north to escape persecution through Christianization (Keskinen, 2019). The Sámi now live in northernmost Scandinavia and Russia’s Kola Peninsula in an area known as Sapmi (Beach, 2015; DuBois, 2016). Unfortunately, colonization and Westernization have had particularly traumatizing, longer-lasting impacts on the Sámi, in comparison to the Finns (Kuokkanen, 2000).

The Sámi are perhaps most widely recognized for their practice of reindeer herding. However, reindeer herders comprise only about 10% of the population today and tend to be among the wealthiest Sámi (Vidal, 2016). The majority of the Sámi remain impoverished and continue to experience intergenerational trauma from past assimilation policies during colonization by Norway, Sweden, and the Finland parliament (DuBois, 2016). As of 2016, human rights for Sámi guaranteed by these parliaments have reportedly not been met (UN Human Rights Council).

Discrimination continues today through failed governmental policy efforts and proposed railroads or pipelines in Sapmi that would cross traditional hunting grounds and disrupt reindeer migration (Vidal, 2016). Along with the Finns, the Sámi experience one of the highest rates of suicide in Europe. Many of them do not trust or know how to engage with healthcare providers for fear of endangerment (Dagsvold, Møllersen, & Stordahl, 2015; Lewis, 2011). Little research has been conducted on Sámi Americans. Perhaps, it is easier this way.

Immigration to the United States

Finnish immigrants to the United States were largely composed of a landless, unskilled working class, which migrated to escape famine and drought (Susag, 1998). The first wave of immigrants to arrive in the United States were primarily men in search of manual labor positions. Upon arrival, many sought any jobs they could find (Taramaa, 2009). According to research by Riselay (1983), approximately 85% of these men were rural peasants, who “entered the American market on the bottom rung of the employment ladder as low-skilled, unpaid laborers.” Many found work in the mines and lumber camps of northern Minnesota and Michigan; in particular, mines were desirable as a miner could potentially earn fives time as much than a farm worker would in Finland (Lavigne, 2017; Arvio, 2019).

Beyond the search for manual labor, many other Finnish immigrants hoped to get into agriculture to establish small independent farms (Riselay, 1983). Unfortunately, the farmers who did settle in the Upper Midwest found it difficult on the thin soil top layer (Niemi, 1921). Farms that were established and remained in the family for generations became successful, despite the harsh terrain. They contributed to local cooperatives, or businesses meant to promote local community and businesses, by selling common goods in bulk which reduced costs (Holmio, 2001; Spady, 1977). These established farms were typically independent, small family farms, which became a well-known symbol of Finnish American culture (Mathers & Kaupi, 1963).

When copper and iron were discovered in the Upper Midwest, Finnish laborers joined the Italian, Swedish, German, English, and Croatian immigrants in the mines that fueled the U.S. military and economy (Nikkola, 2015; Remlinger, 2009; Spady, 1977). Although many ethnic Europeans faced various forms of discrimination and classism, Finnish immigrants experienced significant ostracization. Finnish miners were employed in the most physically demanding, lowest-paid positions, worked the longest shifts, and had the longest work weeks (Lucas & Buzzanel, 2004). Finns were given the most labor intensive positions in the mines and worked as “trammers,” laborers who pushed carts weighing 1,200 to 3,000 lbs., loaded with 1½ to 2½ tons of rock along hundreds of feet of track multiple times a day (Gedicks, 1977).

Unfortunately, immigrants who worked alongside the Finns struggled to understand Finnish culture, which contributed to segregation in mining towns. Although Finns experienced traditional immigrant hardships, their customs and racial status were strongly questioned and often bastardized (Huhta, 2014). Finnish workers were disproportionately portrayed and negatively stereotyped for their alcoholism, knife-fights, and strange customs, such as sauna bathing and cupping (Kaups, 1976; Nordskog, Hautala, & Salmela, 2010).

In addition, polarization among Finns resulted from political movements in the old country (Susag, 1998). Many Finnish immigrants held on to socialist ideals, while others were dedicated members of the rigid Laestadian Lutheran Church (Grantham, 2005; Lubotina, 2015). In the Upper Midwest, Finns established social organizations, newspapers, and local farming cooperatives as a means of community and survival (Huhta, 2015; Spady, 1977; Holmio, 2001). However, this drew attention to what other immigrants considered to be leftist political ideologies. Some Finns were stereotyped as radical socialists in a time when Communism was strictly anti-American (Huhta, 2015; Kostiainen, 1990).

In Minnesota, discrimination against Finns was particularly notable in communities where Swedes and Germans composed a significant proportion of the population (Huhta, 2014; Lavigne, 2017). Finns struggled to assimilate into mainstream Americanized “white” culture, while other European immigrants swiftly acculturated. In particular, Finns were highlighted for their strange customs, such as knife fighting, were labeled as drunks or were described with such derogatory terminology as “jackpine savages,” and faced ostracization along with Native Americans (Huhta, 2014; Lubotina, 2015). After the mines closed, the majority of immigrants moved out of the region. This trend, in conjunction with the rural area, provided opportunity for Finns to maintain cultural norms within close-knit communities (Grantham, 2005; Lewis, 2011; Lockwood, 1977).

In 1907, Finnish immigrant John Svan had his United States naturalization papers rejected by Minnesota District Attorney John C. Sweet (Holmio, 2001; Huhta, 2014; Kivisto & Leinonen, 2011). Sweet stated that Finns did not fit into the U.S. Census categories of “free white persons… aliens of African nativity or persons of African descent” (Huhta, 2014; Kivisto & Leinonen, 2011). In addition, Sweet reasoned that Finns’ ties to socialism, which he labelled an “East Asian philosophy,'' validated ethnic stereotyping that Finns were related to Mongolians (Homio, 2001; Huhta, 2014). Although Sweet’s ruling was overturned two weeks later by a federal judge, the racial identity of Finns in America remained ambiguous.

A significant proportion of Finnish American families took three generations to adopt the English language (Nikkola, 2015; Remlinger, 2009). Discrimination and a cultural value of rurality have led many Finnish Americans to remain in the Upper Midwest. This region, known as the “Finn Hook,” consists of the Arrowhead region of Minnesota, northernmost Wisconsin, and the Upper Peninsula of Michigan (Lockwood, 1977). The rural location allows Finnish American locals to maintain ethnic traditions, without being exploited or facing pressure to assimilate into mainstream American culture (Spady, 1977; Lockwood, 1977).

According to research by Stoller (1996), approximately 66% of Finnish Americans have visited Finland at least once in their lifetime. It is not uncommon to see cultural paraphernalia around the Upper Peninsula, particularly in strongly traditional towns, such as Marquette, Hancock, and Houghton. Many family farms still remain and interact with the handful of remaining cooperatives in the western Upper Peninsula. In Hancock, Finlandia University is the sole institution of higher education in North America that was founded by Finnish immigrants (Arvio, 2019). Finlandia maintains strong connections to Finland and plays a central role in Finnish American culture and lifestyle in the western Upper Peninsula (Arvio, 2019).

Today, many residents of Hancock and the western Upper Peninsula will identify as Finnish and/ or Sámi American. Cultural celebrations take place at Finlandia University, where the university hosts visitors from Finland. Visitors from across the world come to celebrate during the annual FinnFest, which is held at various locations across the Midwest. Traditional values remain strong in the Upper Peninsula of Michigan, where residents are proud of their working-class Finnish American culture and heritage (Keskinen, 2019; Remlinger, 2009).

Finnishness as Cultural Identity

The construct of Finnishness is a shared ethnic identity that depends on the individual(s) with Finnish heritage. In the case of Finnish Americans, symbolism and imagery of Finnish culture within the context of North America brings about a sense of unity. Although Finnishness was originally demonstrated as a sense of nationalism, it is now strongly represented as a means of heritage preservation and ethnic pride among Finnish Americans, particularly in the Upper Midwest.

Although many first-generation immigrants experienced a cultural blending with mainstream Americanized culture, a revival has occurred through subsequent generations, and is exhibited through specific symbols and cultural norms that are still seen today. There are few articles on Finnish American culture and lifestyle into the 2010s. Therefore, Finnishness is defined based on collective ideologies from articles throughout the latter half of the 20th century, until the time of this article’s writing. Cultural norms of the contemporary Finnish American’s Finnishness are represented through thesymbols and images that are outlined below.

Finnish Cultural Norms

Silence

Finnish people find comfort and meaning in quietude (Carbaugh, Berry, & Nurmikari-Berry, 2006; Lewis, 2011). Visitors to Finland might be surprised to find themselves surrounded by silence, upon taking an inner-city bus ride. Although this phenomenon stands out to Americans, the Finnish cultural tendency of quietude remains largely unconscious and is generally accepted as a part of everyday life. The concept of Finnish silence can be complex even to Finns, who might initially describe themselves as shy upon first meeting Americans (Berry, 2015).

Reticence and quietude allow for the typically introspective Finn to be alone in his thoughts (Lewis, 2011). Furthermore, small talk is not the norm for Finns, who listen attentively and view silence as constructive and communal (Lewis, 2011; Nishimura, Nevgi, & Tella, 2008). In Finnish culture, silence serves as an action and influences people to think before they interact with others (Nishimura, Nevgi, & Tella, 2008).

Although Americans might assign a negative value to silence, Finns view it as positive and a sign of comfort and trust (Berry, 2015). As an action, silence serves as a means of showing respect. However, this can be misconstrued for shyness or coldness by persons unfamiliar with Finnish culture. Consequently, a fear of being misunderstood has caused many Finnish Americans to develop a reluctance to break their silence, which reinforces a lack of help-seeking behavior (Berry, 2015).

Although Finnish Americans have adopted mainstream Americanized culture, they have experienced traumas that have had lasting impacts. Since institutional and historical trauma still play an active role in the lives of Finnish Americans, healthcare providers must remain reflective and self-aware. Over time, providers who learn cultural competencies can improve the quality of care. In addition, those who demonstrate cultural humility and cultural sensitivity, can heal indigenous persons from trauma, by slowing and mitigating damage from the intergenerational cycle.

Rurality

Finland’s population of greater than five million people, in combination with its large surface area, makes for comfortable rural living for the majority of its residents. Upon their arrival in the United States, Finnish immigrants chose to settle in the rural areas of the Upper Midwest, which is similar in geography to Finland (Louvinen, 1997; Russell, 1937). The isolation of the Upper Peninsula is a quiet, sparsely populated place for residents to maintain cultural norms, while creating insider/ outsider identities with non-residents (Arvio, 2015; Remlinger, 2009). Rural location allows space for residents to practice ethnic traditions in an isolated area, without pressure to assimilate into mainstream Americanized culture (Nikkola, 2015).

The effect of rurality cannot be denied on the preservation of the Finnish American culture, particularly the stereotype of the rugged outdoorsman (Kushnir, 2016). Although self-reliance and independence remain traditional values revered in rural culture, in particular, Finnish Americans revere the idea of the tough, solitary individual. This value is demonstrated in the value of hard work, the symbol of sisu and the preference of the Finnish American for solitude in the wilderness (Kushnir, 2016). The Finnish American demonstrates rugged individualism through these aspects, as well as in his silence, which also can be used to demonstrate neutrality in specific subject matter.

Egalitarianism / neutrality

Egalitarianism plays a central role in Finnish culture and is relevant to Finland’s international renown for neutrality. This is demonstrated in politics, a cultural value of civic engagement, and gender equality. In 1906, Finland was the first country in Europe to grant women the right to vote (Lähteenmäki, 2017). Finland was dependent on a neutral status to remain its own nation between the Swedish Crown and Russian Empire. Therefore, neutrality and egalitarianism became a mechanism for survival, as all citizens worked to ensure the nation’s independence (Lewis, 2011). Today, Finnish men and women are held as equals in almost all aspects and levels of society and as such, in 2016, Finland elected one the world’s youngest ever female prime ministers (Lähteenmäki, 2017).

Although the first wave of Finnish immigrants to the United States were mostly immigrant men, the women who followed took up positions almost immediately. The immigrant men worked hard labor jobs, while women served as maids or boarding house managers (Arvio, 2019; Holmio, 2001). When a family was able to establish a farm, the women took charge of the family unit and household duties ,while men worked in the fields and/ or mines. In fact, one individualistic Finnish woman named Margareeta Kontra, or, “Maggie” Walz, served as a government agent who decided to try to establish her own Finnish town, after starting her own businesses (Holmio, 2001).

Mrs. Walz bought land on Drummond Island and began to colonize the area. She carved out a community from the desolate woodland that existed for most of three decades (Holmio, 2001). Though the community was short-lived, Maggie serves as a reminder of the strength and individualism represented by many of the Finnish immigrants who came to the United States, as well as an example of egalitarianism.

The discrimination and segregation that occurred in the mining communities and during the labor movements in Minnesota separated the Finns from other immigrant groups, which encouraged bad press and continued slurs (Huhta, 2014). This ostracization of radical Finnish individuals encouraged many within both the conservative and socialist Finnish American communities to lean into neutrality to reduce ongoing violence. As time passed, the Finnish American grew accustomed to maintaining a mostly neutral status as a unique example of an immigrant subculture (Huhta, 2014).

Although the Finnish American presence is well-known today in the Upper Midwest, besides regional jokes about the local characters and accents or stories told by elderly family members, the Finnish American presence remains neutral (Spady, 1977). Cultural dualism developed as the immigrant adapted to America, two cultures became one Finnish American culture, and his presence became more neutral, as he adapted to the new environment which he was determined to call home (Spady, 1977; Taramaa, 2009).

Cultural dualism / multilingualism

Prior to Finland’s declaration of its official language in 1863, the ruling nobility spoke Swedish while peasants spoke the Finnish and Sámi languages. Though Finns spoke their native tongue centuries prior to colonization, Finnish became a symbol of the nationalistic sentiment called Finnishness that led many proud, yet impoverished Finnish emigrants to be judged in Europe, as well as in the United States (Taramaa, 2009; Kirby, 2006). As Finland modernized along with Western Europe, Finns gradually gained international recognition as a distinct people with their own culture and language.

In Norway, Sweden, Finland, and Russia, the Sámi were unfortunately subject to forced assimilation by local and/or national governments. In Norway, in particular, the Sámi were targeted in an aggressive assimilation process called Norwegianization. The government viewed the Sámi people as primitive and wanted to change them into “good” Norwegians (Grenersen, 2012). From 1892 through 1962, Sámi schoolchildren were prohibited from learning Sámi and were taught Norwegian in school (Grenersen, 2012). Many Sámi children were forcibly sent to boarding schools, where they were required to adopt Norwegian culture and language (Kent, 2019). Sámi who refused to assimilate were sometimes killed (Kent, 2019).

For both Finns and Sámi, multilingualism was a survival mechanism developed as a consequence of colonialism (Hieta, 2017). This skill became particularly important to the Finns and Sámi as a means of ethnic survival, when Sweden, Russia and Norway attempted to integrate their cultures (Dagsvold, Møllersen, & Stordahl, 2015). In the United States, multilingualism assisted laborers throughout the process of assimilation. However, Finns took longer to assimilate than other European immigrant groups (Kostiainen, 1990; Spady, 1977; Stoller, 1996).

In the Upper Peninsula of Michigan, Finnish was the main tongue in “language island” communities, where high concentrations of Finnish residents slowed the adoption of the English language (Kostiainen, 1990; Loukinen, 1997l Remlinger, 2009; Ross, 1988). Immigrants spoke Finnish and broken English, while first-generation children almost exclusively spoke English. This was seen as an accomplishment (Niemi, 1921; Remlinger, 2009). Finns ensured that ethnic identity was passed on through privately funded school programs, where children also learned the Finnish language and cultural norms (Spady,1977). Nevertheless, many first-generation Finnish Americans never fully learned to speak the English language.

Residents of the Upper Midwest now speak Finglish, a regional dialect that uses English words within a Finnish grammatical framework (Hovi, 2019). Residents of the Upper Peninsula speak a more localized dialect of Finglish called Copper Country English--or “Yooper,” as it is more commonly known (Remlinger, 2009). Bilingualism of Americanized English and the Finglish dialect has resulted in code-switching behavior, when speakers of both are present. Code-switching can be utilized as a means to alert other Finnish Americans of danger or explain a situation to elders who might not be as familiar with Americanized English (Lauttamus, 1999).

The slow process of assimilation affected language adoption and integration of Finns into the American lifestyle. Although Finns adopted American cultural norms, they continued to maintain a strong ethnic identity, which led to development of cultural pluralism (Nikkola, 2015). As a result, residents of the Upper Peninsula continue to celebrate both Finnish and American holidays, such as Midsummer and the Fourth of July (Nikkola, 2015; Nixon, 2017). Finnish Americans also have their own unique holidays, such as St. Urho’s Day which was originally created in jest but has now become tradition (Hieta, 2017; Hovi, 2019).

Sauna

Sauna is a steam bath invented by Finns that has been utilized for health and spiritual purposes for hundreds of years. In fact, the term sauna applies to the steam bath, as well as the physical building in which bathing takes place. Sauna has become internationally recognized due to its widespread commercialization during the past century. However, little is known about the history behind it (Eteläkoski, 2017). Sauna is now central to contemporary Finnish life and is shared by friends, family, co-workers, and classmates. For Finnish Americans, sauna is “a ritualized enactment of cultural expression” (Lockwood, 1977).

In Finnish culture, it is said that the sauna is a place that is considered for birth, death, and medical practices in between. Finns have long used the sauna for rite-of-passage ceremonies and rituals. Prior to colonization, sauna was a place where the soul was healed and spirits housed (Eteläkoski, 2017). According to Niendorf (2000), the sauna was a place of “preparation for weddings and festivals, to heal the ill, give birth, dry flax and cure meats, and ... prepare dead for burial.” Magic and sacred rituals were also held in the sauna (Eteläkoski, 2017; Niendorf, 2000). Medicine women hung herbs to heal the sick and cupping was performed to suction out “bad blood” or bad spirits (Eteläkoski, 2017; Kaups, 1985).

The contemporary sauna building is a two-room structure with an entry room that serves as a dressing room and a second room used for bathing (Lockwood, 1977; Tsonis, 2017). The entry room has a window, which is opened to allow steam to escape. The bathing room contains elevated platforms, where individuals sit next to a stone-covered stove to which water is applied to create steam. In Finnish, this steam is called löyly and translates to “spirit” or “soul.” (Tsonis, 2017). In the sauna’s front room, löyly is able to escape from the open window.

Steam baths last between ten minutes to a couple of hours and are subsequently followed by a “cool down” (Mathers & Kaupi, 1963). Bathers may whip their legs with birch whisks called vihta to stimulate circulation (Kaups, 1976; Tsonis, 2017). To cool down, individuals jump into a snowbank, a lake, or a cold shower (Mathers & Kaupi, 1963). At the cottage, sauna cool down is a family event that takes place in the lake (Carlisle, 2014; Tsonis, 2017).

The summer cottage is typically devoid of technology and sauna is an opportunity to practice primitivism associated with Finnish culture (Eteläkoski, 2017). Finns visit the cottage to return to nature and regular visits provide a break from the demands of work and stress associated with contemporary society (Mather & Kaupi, 1963; Eteläkoski, 2017). The mental and physical health benefits of sauna during a cottage trip promote a sense of purity associated with naturalism. Hence, sauna represents a return to innocence and spiritual recovery (Eteläkoski, 2017; Lockwood, 1977).

Visitors or friends unfamiliar with Finnish culture might be surprised to learn the shyness they expect of Finns does not apply in the context of sauna. Sauna is a regular part of Finnish life and it is common for Finns to sauna together naked, albeit separated by gender. Family, co-workers and neighbors alike may attend sauna after a day of work or a social event. Cultural values of egalitarianism and ambiguity foster acceptance of nakedness in the sauna (Eteläkoski, 2017). Nakedness, according to one Finn, allows the individual to not only “divest [oneself] of [one’s] clothes, but also of possible prejudices and preserves” (Tsonis, 2017). Finally, nakedness symbolizes vulnerability, which equalizes everyone in the sauna and encourages relaxation and honest conversation.

The process of sauna and cool down has well-studied mental and physical health benefits (Hannuksela & Ellahham, 2007; Tsonis, 2017). Sauna baths improve lung function, by increasing vital capacity and volume, They also reduce pain for individuals with musculoskeletal disorders, such as fibromyalgia (Laukkanen, Laukkanen, & Kunutsor, 2018). Finally, cardiovascular benefits of sauna include reduced blood pressure for individuals with hypertension and decreased arterial stiffness (Laukkanen, et al., 2018).

Sauna also has mental health benefits. Finns have long utilized sauna to heal stress, anxiety, and depression (Eteläkoski, 2017). For example, Finnish Americans in the Upper Peninsula would encourage an individual to take a sauna, if they noticed he was depressed or had low spirits (Lockwood, 1977). The psychological recovery that Finns attribute to the sauna stems from liminality experienced during traditional rites of passage (Niendorf, 2000). Finnish Americans who use sauna as a traditional means to cope with stress and depression might not utilize mental health services, which could delay treatment seeking behavior (Eteläkoski, 2017; Petterson, et al., 2009).

Everyman’s right / Roaming

“Everyman’s right,” or right to roam, is the right of persons to access public and private land for recreation (Ervola & Uusivuori, 2014). In Nordic countries, this right is a continuation of ancient tradition practiced by the region’s first inhabitants. Finnish “everyman’s right” allows persons of any nationality freedom to access public and private land and to collect wild berries for household and commercial use (Vaara, Saastamoinen, & Turtiainen, 2013).

In the Upper Peninsula of Michigan, Finnish American families continue this tradition, where they have hunted and picked berries in specific areas for generations (Carlisle, 2014; Lind-Riehl, et al., 2015). Though the majority of the land in the Upper Peninsula is state or federally owned, as in all rural areas, poaching is commonplace. However, poaching serves as an ethnic symbol for Finnish Americans, who value practical land management and self-reliance (Frandy, 2009). For Finnish Americans, poaching, according to Frandy (2009), “is a continuation of nineteenth century tradition, rooted in a complex of individualism, poverty, and traditional reliance upon the local forests and rivers for food.”

Some families also have several berry-picking spots which they visit throughout the various seasons. Many families have had berry-picking spots that they have kept secret throughout their generations (Frandy, 2009). This can be on state land and can be symbolic of the everyman’s right, which is commonly utilized for berry-picking in Finland. Today it is not uncommon to witness Finnish families picking berries alongside roads in rural areas across the United States, particularly the Midwest, a remnant of everyman’s right still exhibited from an ethnic past (Carlisle, 2014).

Sisu

The cultural construct of sisu is integral to Finnishness for many Finnish Americans. Sisu is a Finnish term that roughly translates to “guts,” and means resiliency, stubbornness, perseverance, determination in the face of adversity, calmness, hardiness, self-reliance, and toughness (Lahti, 2019; Lucas & Buzzanel, 2004; Spady, 1977). The Finnish American experience often circulates this term as a social symbol, along with images of the Finnish flag and a map of the Upper Peninsula of Michigan (Arvio, 2019).

Sisu has often been utilized by individuals of other cultures as a mantra. However, it remains strictly a Finnish word, and has a particularly sensitive meaning for Finnish Americans. Sisu is almost mysticized and simultaneously invokes a sense of unity in Finnish Americans, as well as a quiet pride (Arvio,2019). Sisu epitomizes the determination of Finns throughout centuries of hardship and war, and the heritage of Finnish Americans in the United States. Finnish Americans find personal meaning in sisu, due to perseverance in the face of ethnic discrimination by other immigrants in the United States (Taramaa, 2009).

Since the concept of sisu is powerful, it should not be a surprise that this term is respected by many who hear about it. However, sisu has significant historical and cultural meaning and is not to be appropriated. Actions to use this term by non-Finnish persons are exploitative and harmful regardless of an acknowledgement of the historical context. Rather, non-Finnish people should recognize the sensitive history behind sisu, and respectfully understand that this term should not be misused or commercialized.

Community

Community and kinship are important in Finnish American culture, despite values of independence and family. Finnish Americans collectively identify with their heritage, even if communication is at times lacking (Arvio, 2019). The discrimination that immigrants historically experienced in mining communities brought Finnish immigrants to settle in highly localized communities (Arvio, 2019; Lockwood, 1977; Stoller, 1996). Finns established temperance halls that hosted events and clubs, which became centerpieces of Finnish American communities and served as a means of avoiding drinking or fighting (Sariola, 1985). Community and kinship continue to be a form of cultural expression in the present day, which is demonstrated through family gatherings, festivals, community events, and trips to the cottage.

Intergenerational trauma, depression, and substance use

The Upper Peninsula has high rates of unemployment, depression, and substance use (Western Upper Peninsula Health Department, 2018). Finnish Americans are a working-class culture that is rooted in norms of fortitude and rurality, and remain in the area despite the lack of available jobs (Keskinen, 2019; Lucas & Buzzanel, 2004; Taramaa, 2007). According to the Upper Peninsula Community Health Needs Assessment, in 2018, there were only thirty-one psychiatrists for a population of 311,000 residents (Western Upper Peninsula Health Department). Unemployment and lack of social services factor into local residents’ alcoholism and depression (Taramaa, 2009). There are also high rates of homelessness, and, social workers who try to mitigate these issues through the few social services available, often feel like they come up shorthanded (Mackie, 2012). Unfortunately, area youth have high rates of untreated mental health and substance use, which has become accepted as a cultural norm (Western Upper Peninsula Health Department, 2018).

Misunderstanding

Finns have been misunderstood for centuries in Europe, as well as the United States. Finns have linguistic, physical, and genetic characteristics that are distinct from other European populations (Dutton, 2014; Louvinen, 1997). Although these differences create an environment of ambiguity, they also foster misunderstanding by non-Finnish people (Louvinen, 1997). Over time, Finnish Americans have grown accustomed to being misunderstood, which has become a part of their cultural experience.

Humility and modesty

Finnish culture highly values modesty and humility. Like many other rural people, Finnish Americans are not boastful people and they do not find reason to and/ or struggle to talk about their accomplishments with others (Nishimura, Tevga, & Seppo, 2008). Ethnic Finnish Americans take great pride in their work and live by the ethos of working-class culture, while maintaining humility (Keskinen, 2019; Nishimura, Tevga, & Seppo, 2008). However, cultural norms of reticence, humility and modesty can negatively influence treatment-seeking behavior among the Finnish American populace.

If Finnish Americans demonstrate treatment-seeking behavior, they still might struggle to express their emotional, mental, and physical needs. Nonverbal communication is important in this culture, and body language and posture can indicate stress, anxiety, or depression (Lewis, 2011). Body language is a form of self-expression that is often overlooked yet provides detailed insight into the individual’s mental state, if the observer pays close enough attention. This phenomenon has also been observed in other cultures, such as in Japanese or Native American populations, whose communication styles are not unlike that of the Finn (Lewis, 2011; Taramaa, 2007).

Cultural Competencies

Cultural humility vs. humility as a cultural norm

It is important to note the difference between cultural humility as a practice by medical providers and humility as a cultural norm. Humility and modesty are held in high esteem by persons of Finnish heritage, which are to be valued when encountering their practitioners (Hieta, 2017). A medical provider who employs both professional humility and cultural humility will benefit immensely, when he recognizes the opportunity to implement both in practice.

The practice of cultural humility, however, is a means for providers to better accommodate the needs of their patients. Healthcare providers who successfully practice cultural humility remain cognizant of their cultural identity and practice awareness to mitigate bias. Providers who commit to lifelong learning of culturally humble practice can improve access and quality of services for their clients, regardless of cultural norms for both the patient and the provider.

Meaning in the Narrative

According to Nixon (2017), “our narrative shapes how we choose to exist in a specific way and… is one way of reporting past events that have entered into the biography of the narrator.” Minority elders are more likely to respond to providers who focus on collaboration for care (Bushy, 2009). The Finnish American narrative has often remained in familial history, which passed from generation to generation by oral storytelling (Nixon, 2017). As an indigenous people, Finn and Sami Americans can utilize self-narrative as a means to decolonize their struggles and express their needs (Forrest, 2006). Therefore, providers can empower clients in their indigenous cultural identity, by maintaining active listening skills which demonstrates respect.

It is important to note that the indigenous self-narrative is often circular. This narrative style differs from a linear, Westernized timeline (Paradies, 2016). The circular narrative holds significant meaning for indigenous peoples, since it represents many things, including the pattern of nature’s seasons. In circular narratives, individuals may begin in a specific situation, proceed through a journey, then end up in relatively the same situation which they began (Paradies, 2016). This narrative style is symbolic and, though it was used for hundreds of years prior to colonization, it can also be seen as a manifestation of cycles brought by historical trauma.

Client Self-Determination

From an indigenous perspective, self-determination is the ability of an individual to decolonize a personal narrative marked by historical trauma through racism (Mörkenstam, 2005). Many second and third generation Finnish Americans have attempted to reconnect with their ethnic heritage in a pushback against Americanization and Westernization. In particular, third generation Finnish and Sámi Americans have focused in-depth on their cultural narrative through self-determination (Forrest, 2006; Grantham, 2005; Lockwood, 1977). The indigenous right to self-determination is important to the continuity of Finnish and Sámi cultural identity within the United States.

It is recommended that healthcare providers offer Finnish and Sámi American clientele the choice of hospitalization, medication, or both during mental health crises. Mental health and spirituality are inextricably linked to physical health. Therefore, noting a difference will help providers champion cultural sensitivity and cultural humility in their practice. Recognition of spiritual needs and beliefs, which otherwise might be mistakenly attributed to mental illness, is crucial to culturally sensitive care (Fang, et al., 2016; Garrett et al., 2015). The aftereffects of trauma also continue to play a role in the Finnish and Sámi American way-of-life. Providers who utilize cultural humility can use this skill to recognize spirituality, rather than attributing trauma strictly to mental health. This helps to empower indigenous patients and to improve the overall quality of care (Foronda, et al., 2016; Hook, et al., 2013).

Another important need to practice culturally sensitive care is with end-of-life care and decision-making. Many cultures around the world approach end-of-life care and death from a unique perspective. This must be equally respected among the healthcare professionals providing treatment. Healthcare providers should consult with ethnic minority elders in regard to end-of-life care (Foronda, et al., 2015). When practitioners collaborate with ethnically diverse patients, it allows patients the opportunity to practice self-determination, which reinforces patient autonomy. Ethnic elders will be more receptive to treatment and demonstrate further treatment-seeking behavior, when providers collaborate with patients for care plans that are culturally relevant.

A Culture of Resiliency

Finnish American life is centered on working-class values of self-reliance and resiliency. However, cultural expectations of hard work and toughness serve as additional stressors for Finnish Americans. In particular, expectations for independence among Finnish-American elders, who tend to rely on kin for any additional help as they age, can delay treatment-seeking behavior and increase health risks. Successful patient-provider conversation occurs, when providers set up opportunities to offer and discuss treatment options to patients and share the responsibility and control with them (Ha & Longnecker, 2010). Local providers can establish partnerships with one another to improve communication, which can be used as a means to improve treatment-seeking behavior in this ethnic group.

Research indicates that patients may feel disempowered and unable to attain goals, when healthcare providers issue medical information in the form of a monologue (Ha & Longnecker, 2010). Providers might not realize this information delivery method can be particularly overwhelming for patients from diverse backgrounds. This dynamic has established an awareness in patients of doctors’ authority, to which patients have responded by actively tailoring medical advice to suit personal needs (Ha & Longnecker, 2010).

However, this increases risks for patients who do not adhere to strict medical precautions necessary for procedures and post-operative care. When patients and providers engage in mutually respectful dialogue, client anxiety regarding medical information is mitigated. The client can work with the provider to better understand why certain means of practice, procedures, and examinations are medically necessary.

Conclusion

Finnish Americans remain a unique subculture in the Midwest, centered on values of self-reliance and modesty and a working-class lifestyle. However, they will continue to face challenges in access to healthcare, if cultural competencies remain unaddressed. Although many youth leave the Upper Peninsula in search of jobs, minority elders remain and continue to experience disparities in healthcare, due to communication issues in the patient-provider relationship. Healthcare providers must acknowledge the necessity of incorporating cultural humility and cultural sensitivity in practice, along with the use of cultural competencies to reduce any healthcare disparities.

Healthcare providers who continue to incorporate cultural competencies, cultural humility, and cultural sensitivity into practice must commit to lifelong learning and self-reflection. This reduces stigma and builds trust with clients, particularly those from ethnic and/or minority backgrounds. When providers respectfully recognize cultural norms and set up time to collaborate with ethnic minority patients, such as with Finnish Americans, they can achieve optimal care and improve the patient-provider relationship. In this manner, providers can act as advocates for their patients, as well as healers, and can subsequently make indigenous historical trauma a thing of the past.


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