Journal of Nursing Education

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Summers of No Return: Transforming Care Through a Nursing Field School

Kathryn Hopkins Kavanagh, PhD, RN

Abstract

ABSTRACT

Nursing education is developing a wide variety of ways to educate for cultural competence that expedites culturecongruent care and effective diversity management in practice. Using a praxis orientation, this article reports research done on an innovative nursing field school during the past four summers on the Pine Ridge Indian Reservation in South Dakota. Learning context emphasizing formation of a collaborative, caring community is created for 6-week immersion learning experiences during which student groups work with the High Plains OgIaIa Lakota in tribal programs. Triangulated data based on participant observation and student journals, stories, discussions, interviews, academic coursework, and evaluation surveys provide a comprehensive record of complex and multifaceted field school and immersion learning processes. Through collaboration with students, Diekelmann's "Concernful Practices" are tested and adapted for fit as a framework for organizing and examining the field school experience, as well as the practice of health care across cultures.

Abstract

ABSTRACT

Nursing education is developing a wide variety of ways to educate for cultural competence that expedites culturecongruent care and effective diversity management in practice. Using a praxis orientation, this article reports research done on an innovative nursing field school during the past four summers on the Pine Ridge Indian Reservation in South Dakota. Learning context emphasizing formation of a collaborative, caring community is created for 6-week immersion learning experiences during which student groups work with the High Plains OgIaIa Lakota in tribal programs. Triangulated data based on participant observation and student journals, stories, discussions, interviews, academic coursework, and evaluation surveys provide a comprehensive record of complex and multifaceted field school and immersion learning processes. Through collaboration with students, Diekelmann's "Concernful Practices" are tested and adapted for fit as a framework for organizing and examining the field school experience, as well as the practice of health care across cultures.

Heightened commitment to recognition of rights for reference groups and increased client involvement in health care imply expectations for care that matches cultural orientations (Andrews, 1992; Hornby, 1993; Leininger, 1988; CNeil, 1989). Diversity management, which is defined by Thomas (1991) as helping each individual or group reach its full potential, is central to nursing practice. Nurses today face a need to become adequately culturally competent to allow them to expedite culture-congruent care (Leininger, 1988) and effective diversity management in practice.

While nurses increasingly accept responsibility for focusing care on patient-centered perspectives, learning to care remains shaped in large part by traditional discipline-driven and market-driven priorities. Nursing education has only recently focused on developing effective ways to teach for cultural competence and diversity management. Educational strategies that foster academic achievement as well as development of cultural competence and the ability to understand and critique social order (Baer et al., 1995; Fiol-Matta & Chamberlain, 1994; Geismar & Nicoleau, 1993; Ladson-Billings, 1995; McAllister & Ryan, 1995; Nieto, 1992; Orlandi, 1992; Schoem, Frankel, Zuñiga, & Lewis, 1993; Siegfried, Getz, & Anderson, 1995) are being vigorously explored by nursing educators (Bartz, Bowles, & Underwood, 1993; Nehls, 1995; Schaperow, 1991; Thompson, 1987).

Adopted designs tend to focus on dialogue and the formation of community (Diekelmann, 1991; Porter, 1995), an idealized collaborative culture of caring in learning settings (Diekelmann, 1991; Meléis, Hall, & Stevens, 1994; Wuest, 1992), and curricular change (Gagnon, 1983; Schoem et al., 1993). However, curricula that emphasize sensitivity, knowledge, and skill areas relevant to culture and diversity can fall short of maximizing opportunities for learning cultural competence (Hornby, 1993; Princeton, 1993) when they are adapted to conventional nursing education settings (Beck, 1995; Bowser, Auletta, & Jones, 1993; Crow, 1993; DeSantis, 1991; Eliason & Macy, 1992; Smith, Colling, Blander, & Latham, 1993). Learning experiences that remain within relatively familiar (albeit secure and predictable) circumstances may demand greater adaptation to the cultural orientations of nursing and medicine than to situations in which the world views of clients prevail.

One innovation involves field school experiences with tribal programs on an Indian reservation. As an educational context, the field school facilitates immersion learning experiences (Kavanagh, 1995) that can play a vital role in culturally competent professional socialization. Although infrequent in nursing, immersion experiences are not unknown (e.g., Bond & Jones, 1994), and the concept has been indirectly encouraged, although usually with international application in mind (Styles, 1993; UhI, 1993). On the other hand, field study methods are traditionally used in anthropology to facilitate deepseated familiarity with indigenous points of view (Gifford & Morris, 1985; Joiner, 1992; Kardiner & Preble, 1961; Kushner, 1994; Mandelbaum, Lasker, & Albert, 1963). In anthropology, the field school is in large part an artifact of going where the evidence is, often to facilitate its actual discovery. The same effect can greatly benefit nursing.

Applied to contemporary circumstances emphasizing health and illness within a specific cultural context, field study is the essence of opportunity for participant observation (Spradley, 1980; Whyte, 1955). Premised on the conviction that the "best way to learn about a culture is directly from the people" (Broken Nose, 1992, p. 382), the proximity of opportunities to learn from cultural experts in naturalistic settings combines with the intensity of immersion in field school experiences to encourage a focus on how learning (Diekelmann, 1991) about culture and diversity occurs as it relates to caring.

Field school participation is not easy. Fieldwork, because it necessitates learning to function in a new social world, is fraught with the stress of culture shock and emotional, as well as intellectual, challenges (Corsino, 1987; Golde, 1970). Individuals, when responded to by native standards, may be surprised by unforeseen disparities (Wax, 1986). Participante begin to glimpse what it means to live simultaneously in two worlds (Hobus, 1990), something with which members of many American Indian and other ethnic groups must contend on a daily basis.

Field schools, on the other hand, also foster close collaborative teamwork and opportunities for development of supportive relationships with others with whom the learners share significant commonalities, while negotiating their way and establishing rapport in an unfamiliar setting. They promote development of emic/etic (or insider/outsider) approaches that facilitate cultural brokerage (DeSantis, 1991) and effective (that is, mutually acceptable and enabling) negotiation between indigenous models of understanding and postulated modalities of curing and caring (Kleinman, 1982; Kleinman, Eisenberg, & Good, 1978).

Using a praxis orientation (Singer & Beer, 1995; Warry, 1992), data for this article came from four summers' intensive participant observation in a nursing field school in collaboration with student contributions including journals; stories and discussions; informal interviews before, during, and following the field school experience; academic coursework during and subsequent to the field school; and repeated evaluation surveys. Extensive fieldnotes kept by the instructor and students recorded participant observational data on the complex processes of a field school focused on personal and professional development of intercultural sensitivity, knowledge, and skills. Data analysis employed comparative techniques for identification of themes and patterns and hermeneutic analysis of journal and observational data. Before and after leaving the field, students worked with the instructor to edit videotapes and manuscripts related to their experiences. The varied data sources and participatory analytical techniques provide insights into experiences from learners', providers', and teachers' perspectives.

FIELD SCHOOL SETTING

Approximately 20,000 Oglala Lakota, a High Plains American Indian group known officially as the Oglala Sioux Tribe, live on the 5,000 square mile Pine Ridge Reservation in South Dakota, with the Badlands to the north and the Black Hills to the west (Russell, 1993). The Massacre of Wounded Knee, symbolic as a nearly terminal blow to survival of native cultures, occurred in 1890 at Pine Ridge (Gagnon & White Eyes, 1992; Utley, 1963). Today, the reservation is the second largest of the United States' 278 federally designated Indian lands and is the site of the nation's economically poorest population. With a per capita income less than half the national poverty level (L. Cottier, personal communication, 1993-1995; Gagnon & White Eyes, 1992; Little Eagle, 1993) and with more than 80% unemployment (Gagnon & White Eyes, 1992), the Oglala Lakota endure the problems of many oppressed groups (Bohannan, 1992; Braithwaite & Taylor, 1992; Dressier, 1993; Giago, 1984; M. Her Many Horses, personal communication, August 1, 1993; Roberts, 1983). For example, the age-adjusted alcoholism death rate for American Indians and Alaska Natives is 5.4 times the rate for all races in the United States, and young adult Indians are more than twice as likely as non-Indians to commit suicide or die in a car accident, with at least 75% of those suicides and accidents being alcohol-related (DuBray, 1992).

Despite demonstrable resilience and determination to reclaim and retain a strong ethnic identity (Boldt, 1993; Clifton, 1993; E. Deloria, 1992; V. Deloria, 1969; Ortiz, 1977), which is associated with positive health outcomes in other American Indian groups (Guilmet & Whited, 1989), the primary causes of Oglala Lakota morbidity (accidental injuries, cirrhosis of the liver, alcoholism, attempted suicide, attempted homicide, malnutrition, pancreatitis, gastrointestinal bleeding, fetal alcohol deformities, mental and emotional disordere, organic brain syndromes, and alcoholic heart disease) and mortality (accidents, heart diseases, cirrhosis of the liver, suicide, and homicide) reflect long-term demoralization and domination (Dinges & Koos, 1988; Gagnon & White Eyes, 1992; Helman, 1990; Johnson & Sargent, 1990; Landy, 1977). Average life expectancy on the Pine Ridge Reservation is 47 years (United States Bureau of Census, 1991); the tribe hopes to increase it to age 50 by the year 2000 (Yellow Hair, personal communication, June 26, 1994).

The Oglala Lakota are a people working hard to maintain their unique identity in the thick webs of federal bureaucracy and developing tribal self-governance. Their economic poverty is obvious, but the positive influences of the extended family and cultural tradition take longer to absorb if one is unaccustomed to Lakota ways, as does appreciation for the resilience and determination that has helped American Indians to endure a political environment that recurrently plays the antagonist. Today the Lakota struggle to retain and celebrate their culture, which not long ago was considered illegal. A few fit the drunken Indian stereotype, but many more strive to stabilize the community and work for its improvement. They want what most people want: jobs, safe housing, and an opportunity to be who they are.

PROGRAM AND PERSPECTIVE

For each of the past four summers, 10 to 12 students from the University of Maryland at Baltimore School of Nursing participated in 6-week field schools on the Pine Ridge Reservation. The experience is a collage of self- and peer-instruction, individual and collaborative learning. Most participants are graduate nursing students, but others have included social work and anthropology students, a rabbi on sabbatical, representatives of other disciplines, and undergraduate nursing students. Self- funded, the group lives collectively and inexpensively in a Bureau of Indian Affairs school dorm and works with various tribal health-related efforts across the reservation. Each student enrolls for three university credit hours of the course, Health, Health Care and Culture; some earn additional independent study credit. The faculty member responsible for the field school and accompanying the students is a nurse anthropologist with a background in psychiatric/mental health nursing and cross-cultural counseling.

For the field school participants, the Lakota are experts who can and do communicate the realities of their varied lifestyles. Only they have rights to and can share their cultural knowledge (Pinel & Evans, 1994). It becomes apparent in the field setting that there is no simple or single answer to providing health care, and any attempt to formulate one shortchanges complex and littleunderstood processes. With time, immersion, and reflection, insights are gained into taken-for-granted understandings and assumptions that influence everyday life (Wittgenstein, 1969). In that regard, students often remark that a few weeks of immersion living can equal any number of semesters of classroom and clinical instruction.

IMMERSION LEARNING

Learning and teaching during the field school are profoundly affected by three circumstances. First is the creation of a sub-community of participants that functions as a collaborative, caring group. With the advent of commuter campuses and the fading of nurses' residences, students typically have no prior experience with communal living and respond to it in diverse ways. Students of nursing, on the other hand, are acquainted with group and teamwork processes that others may not be. Second is, as one student put it, that "[w]e can't go home at night." Immersion, by its very nature, provides nearly limitless "teachable moments" (Diekelmann, 1991; LadsonBillings, 1995) and learning opportunities. The 1,900 miles between Pine Ridge and Baltimore pull together individuals who might find less in common on campus. Third, the field school setting facilitates exploration of alternative perspectives by minimizing contact with familiar bureaucratic organizations (including the Indian Health Service) and maximizing exposure to and experiences with tribal endeavors, Depending on student interest, background, and mobility, participants are guided to and then select disparate tribal programs with which to work for 20 to 30 hours per week toward that program's goals. An effort is made to ensure the students work with Lakota rather than other students.

The fact that learning occurs through sharing experiences and creating conversation is abundantly apparent in the immersion setting. Student-teacher relationships and reflexive scholarship involve connectedness to form a community of individuals who learn collaboratively. Time spent roaming the reservation together and linking with the land serves as a catalyst for the formation of group identity, as well as for uniting with the people encountered. Attending festivals and ceremonies (e.g., Sundance, powwows, give-aways, sweats, and naming ceremonies), particularly after getting to know members of the tribe, reinforces that connectedness. Numerous videotaped documentaries (and a video monitor) and dozens of books transported to the field serve as additional resources, as there are no libraries on the reservation. Many evenings are spent in part watching and discussing documentaries, often joined by Lakota acquaintances. The student group also celebrates meaningful events of its own, such as religious events, birthdays, and anniversaries, and frequently invites friends from the Lakota community to dinner. The goal is an atmosphere of open, continuous dialogue, discussion, and sharing- in sum, a dialogical community (Diekelmann, 1991; Porter, 1995) with a culture of scholarly caring (Meléis et al., 1994).

PARADIGM TUGS AND SHDTTS

Given nursing's deeply embedded orientation toward intervention, field school participants are often challenged by the idea that we travel to Pine Ridge not to fix things but to learn. We take to the Lakota virtually nothing that they value, and we are there and do what we do at their invitation and on their terms. Differences in perspective become apparent, are made explicit, and are worked through. The students are generally unaccustomed to close examination of either subtle differences in interactions (Bottorff & Morse, 1994), which can be obscured in cross-cultural communication, or power issues and broader social patterns. For example, when students returned to the dorm exhilarated at having been given the keys to the tribal soup kitchen, their role there was discussed until it could be comfortably redefined as something done with the Lakota rather than to or for them. Long accustomed to handouts and the imposition of goals and services from outside their culture, many Lakota resignedly let "wasichu" (strangers) do things their way on the reservation. The tribal objective, in contrast, is greater self-sufficiency.

While flattening the provider-consumer hierarchy serves as a model for collaborative relationships between health care providers and consumers when bridging cultural differences (e.g., Argyris, Putnam, & Smith, 1985; Dunst, Trivette, & Deal, 1988; Kavanagh & Kennedy, 1992; Rose & Black, 1985), open communication ensures that each individual and group has a voice. For members of intervention-oriented disciplines, the front line becomes a common ground with the creation of interdependency. Ontologically, this position synchronizes with that of traditional American Indians (DuBray, 1992; Hornby, 1993) and the Lakota peoples (Giago, 1984), as well as reflects the suitability of this approach for work with historically oppressed groups.

As an immersion learning program, the field school creates a situation that pulls students into it with a respect for inquiry and new experiences. In some cases, learners must be reoriented toward win-win modes of intercultural communication if their unguided experience has induced a fearful wariness toward difference. Such defensiveness may be a repercussion of striving to use strategies (typically routinized one-size-fits-all approaches) that are designed to lead quickly to positive outcomes but fail when applied across cultural differences. Although changing attitudes is notoriously difficult, in the field school context, immersion and time combine to redefine diversity as an asset rather than a hindrance in providing care. On Pine Ridge, that awareness is triggered when students become enthused about grasping the meaning and impact of subtle, implicit, and abstract differences between the Lakota world view and their own (Crow, 1993). Safety in exploring new ideas is supported by the organization and function of the group.

A conspicuous example of change involves the construct of visiting. Each summer, several students work with Community Health Representatives (CHRs), men and women from Pine Ridge Reservation who, after 3 to 4 weeks of training, are employed by the tribal-organized and tribal-run CHR program to visit clients' homes, where much of the basic care is constituted by visiting. The CHRs also have additional duties not situated in homes, which are as wide-ranging as anifwl control and patient transportation to Indian Health Service faculties. During their summer experiences, students accompanying CHRs on home visits initially characterized the visiting roles as professionally lax because they differ substantively from task-oriented visiting roles in contemporary biomedical settings: "They don't do anything but sit around and drink coffee and talk about their kids" is a typical first- week description. However, by the second week early awareness glimmers". "Something is happening, but I don't know what." Eventually, "The CHRs are doing something when they visit, but I don't understand how" is gradually transformed into "That's what the CHRs do, they visit. Visiting is the intervention."

The cultural revelation that visiting is a goal in itself, rather than a means to an end, comes slowly because of prior socialization forming, in essence, a paralyzed paradigm effect. As products of dominant North American culture with its emphasis on activity, consumerism, time, and productivity, the students initially negatively labeled (Levy, 1988) visiting (both formal and informal), rather than recognizing it as valued, intended, and more than a vehicle for or absence of other activity.

Deeper exploration of Lakota interpretations of visiting relates the construct to everyday communication patterns and to healing as a therapeutic use of self. Visiting is a logical mechanism for exchange, given the Lakota interactive values of interrelatedness, spirituality, silence, and mutuality in healing contexts (Brown, 1953; Bullchild, 1990; V. Deloria, 1992; Eaton, 1982; Finkler, 1994; Powers, 1982); their history of external genocidal and culture-oppressing efforts (Andrist, 1964; Weatherford, 1993); a cultural distaste for unidirectional communication and domination; and an orientation toward holism.

Overall, advocacy among the Lakota takes two forms. On the reservation, the focus is on supporting the choice to reclaim strength and ethnic identity through a revitalization of tribal tradition, that is, to support and empower through accomplishment of Lakota priorities and goals (Dunst et al., 1988; Ellsworth, 1994; Kavanagh, 1993). Off the reservation, advocacy includes Hirmniqhjpg racism and classism as social processes. Students become aware of ways that race in American society is confounded with other social and cultural characteristics, including class (Rothenberg, 1988), of the vital impact of these on lives, and of health care and nursing's typically silent collusion in those social processes (Barbee, 1993; Jackson, 1993; Painter, 1994; Tullman, 1992; Weaver & Garrett, 1983).

Being on the reservation, with its restricted economics (Trattner, 1989) and largely traditional values, invokes reappraisal of living in a consumption-oriented society. Field school participants, after becoming personally acquainted with reservation residents, generally find the tribe's present socioeconomic distinction from mainstream society as unsettling as the deeper exploration and local application of the historically poor treatment of American Indians.

"CONCERNFUL PRACTICES" AS APPLLED TO FLELD SCHOOL IMMERSION LEARNING

As participants in research and learning (Baer et al., 1995), students collaborate with the instructor on the development of a model for teaching that integrates diversity with caring within the context of developing cultural competence. This is a collaborative effort in the truest sense and involves enduring and meaningful relationships (Gottlieb, 1995) through which we work toward culturally responsive critical pedagogy. To that end, we explore, test, and adapt Diekelmann's (1994, 1995) "Concernful Practices" as a framework for organizing and examining the Pine Ridge experience. Developed from long-term research with expert teachers, these broad inductive categories of practices provide an interpretive framework that guides the field school experience. Because of their flexibility and sensitivity, they also fit well with learning processes focused on the practice of health care across cultures.

Welcoming, Gathering, and Accepting

Welcoming, gathering, and accepting involve creating effective relationships and establishing open communication (Seelye, 1993). In the field school, living, cooking, and eating are expected to occur collaboratively. Students choose rooms, and roommates if desired, and focus on settling in individually and collectively. Meanwhile, socialization to the reservation is multidimensional. Most field school participants come from middle-class urban or suburban backgrounds. The tendency to stay with established ways is strong, and prompting is required to leave familiar routines and comforts to investigate the Badlands and rural prairie, explore the reservation without maps, or trek up trackless hills to watch sunsets. Students are encouraged to lie on the ground with nothing in sight but a fringe of grass and endless sky- an experience some have never contemplated and find threatening at first. Such small connections to the land serve to build awareness of the preoccupation with time, linearity, and distancing from nature that pervade modern life.

The field school participants engage in a process of discovery that initially involves a blind following and then a growing awareness and connectedness with the world around them. Within a few days, the dormitory is referred to as home, and the learners are open to adopting into the group additional individuals from outside the reservation who lack a similar support system while on Pine Ridge. Over time, students learn to accept the unpredictability of "Indian time" and not to adhere automatically to driveways and parking lots, but to drive across the school yard as the Indians do. That is, they begin to be critically aware of boundaries taken for granted elsewhere. Dialogue is confirmed as an open medium, private and confidential as well as social and public, for learning (Diekelmann, 19S8).

Staying, Knowing, and Connecting

Staying, knowing, and connecting involve finding meaningful ways participants can contribute on terms respectful of Lakota culture and goals, while learning to recognize both patterns and variations when they occur. As the participants become more mindful of managing their own diversity, questions initiated by "Why don't they...?" are gradually balanced with "Why do we...?," often prompting on-going discussion of various approaches and perspectives. With time, they challenge the groundlessness of their beliefs, the tendency to assume that "Any 'reasonable' person behaves like this" (Wittgenstein, 1969, p. 33e, #254).

As they become more aware of the potency of cultural expectations as well as personal choices, participants find themselves consciously setting priorities and considering options regarding what to accept, reject, ignore, or try to change. Despite learning to respect Lakota views, for example, there are two areas in which field school participants to date have resisted modifying their beliefs and behaviors: their own dietary patterns and their ideas about treatment of animals. Initially critical of local nutritional habits, as well as of the apparent lack of care of doge in an essentially live-and-let-die (as well as veterinarianless) society, over time students begin to appreciate the ramifications of criticizing or interfering with local practices that they only partially understand.

The students made a videotape, borrowing a camera and using school resources for final editing, to capture memories and help communicate their experiences to others (Hagedorn, 1994). Members of the group also became mainstays on the KILI radio program, the "Voice of the Lakota Nation," because colleagues at the clinic in charge of the health show were open to new voices willing to discuss health-related issues. Concepts such as cross-cultural health care become more than rhetoric, and it becomes expected that one learns and respects clients' notions of care before intervening.

Prescencing, Attending, and Staying Open

Prescencing, attending, and staying open are confounded with time, which harangues modern health care and nursing. Routinization and efficiency are valued by the dominant culture, while caring, connecting, and learning take time (Diekelmann, 1993). The context of immersion learning promotes a meld of European American time-urgency with the Lakota value of doing things when they feel right. Visiting, sharing stories, and many other simple experiences become special. Examples include learning about Lakota culture and history (e.g., learning to recognize ancient tipi rings, detecting unmarked graves by finding beads in ant hills, and making and beading personal medicine bags); being invited to visit obscure parts of the reservation with Lakota friends; mindfully appreciating the beauty of the land and sky; sharing successes and failures of acquaintances; and spending time together or alone stargazing, watching sunsets, taking hikes or late-night walks, exploring local points of reference, and even watching documentaries and cooking for up to two dozen people.

Creating a Place and Keeping Open Possibilities

Creating a place and keeping open possibilities entail working to establish caring relationships and increasing sensitivity to our own implicit understandings and expectations. For example, one participant, a teacher spending the summer on the reservation, who was adopted into the group, realized how her zeal for the germ theory created a barrier between her and the Lakota she worked with at the recreation center. Another, being asked for her phone number "in case I need to visit with you," expressed how that simple request expanded her awareness of being present where things and time are less important than relationships.

In addition to sharing activities of daily living, members of the group write collectively, continuously editing, adding, and deleting to articulate their experience. Writing helps to distance experiences and to promote reflection of the larger picture from a variety of perspectives (Sorrell, 1994). The exercise also assists discovery of common understandings in an interdisciplinary group (Sorrell, 1994). After leaving Pine Ridge, the edited manuscript is returned to all contributors for revision and then is submitted for publication (Kavanagh et al., 1995). Some students have kept and shared journals, but cooperative writing projects seem to more effectively increase competence and confidence in this group-oriented learning experience. Students are strongly encouraged, however, to maintain personal records of their journeys, and several have used those for academic as well as personal purposes.

Safeguarding, Preserving, Advocating, and Protecting

Safeguarding, preserving, advocating, and protecting guide awareness that people tend to see what they expect to see and that stereotypes narrow vision by ignoring variations that occur naturally (Brislin, 1993). Learning about diversity and caring involves recognizing and replacing stereotypes with informed, predictable patterns that serve merely as starting points for inquiry and comparison. Advocacy roles require sensitivity, knowledge, and skill (Kavanagh, 1993; Kavanagh & Kennedy, 1992), including a willingness to examine personal values and those of the subcultures of nursing and biomedicine (Good & Good, 1993; Stein, 1990), as well as those of other individuals and cultural groups (Jezewski, 1993). Involvement reflects attempts to appreciate the intricacies of a complex society that is only partially understood and to transform care to fit that world view, becoming aware, for example, of hidden messages (Philips, 1983) in health promotion, models focused on deviance rather than strengths, biased and unfair information, and insensitive descriptions (Broken Nose, 1992; Cohen, 1994). Part of the challenge is to learn the difference between transformation and change; another is to take a hard look at the role of health care intervention in cultural preservation (Hobus, 1990; Leininger, 1988; West, 1993).

Guiding and Guarding

Guiding and guarding exemplify active mentoring. Some students need nudging to consider alternatives to familiar professional and academic models. Guiding can also require confronting students' avoidance of painful or distasteful issues. Caring mentoring is crucial; just as differences can promote either distancing or connecting, doubt can stimulate intellectual inquiry or frighten it away. Similarly, structure must be used sparingly in the field school context to ensure openness to unanticipated opportunity. While too little structure threatens vulnerability and exposure, too much stifles learning.

Such careful orchestration, which signals the difference between learning and being "well taught" (MacLeod, 1995), is demanding when students are immersed in an unfamiliar situation. Because each student comes with a unique history and biography and has a distinct experience adjusting to the reservation, gauging levels and types of mentoring requires cautious and constant vigilance and negotiation. This challenge is deepened by differences of privilège (Ellsworth, 1994) afforded group members in correspondence with their familiarity with the people and place, as well as personal characteristics (Wax, 1986).

Engendering Mutuality and Community

The need for engendering mutuality and community is bi-dimensional in that the field school forms a sub-community within a larger community The extent and way thtt the participants compose a group vary with individual strengths, in particular flexibility, openness, and creativity. From the viewpoint of being visitors to the reservation, concernful attention to mutuality and community compels acknowledgment that most health care providers have not been educated to effectively manage diversity in practice; indeed, prevailing cultural orientations toward efficiency, active intervention, and change encourage minimising attention to diversity. Group discussions emphasize issues related to power that may be minimized or avoided elsewhere, such as race, ethnicity, poverty, political sovereignty, affirmative action, multiculturalism and bilingualism, prejudice and discrimination, and the unresolvable dialectics (Ellsworth, 1994) of traditionalism and modernism and self-determination and perpetuation of dependence.

Letting Be and Letting Go

The intensity of immersion learning necessitates an additional genre of practices that comprise letting be and letting go, which expedite openness to learning during and after the field school experience. Experiences in an immersion context change everyone involved. Those changes affect relationships at home, often in unforeseen ways. For example, when one student asked her boyfriend how he saw her changed by a summer on Pine Ridge, he responded that, to him, she is now on a different plane for which he has no ticket. Despite admonitions, participants tend to underestimate both the changes in themselves and their consequences on their return home. To buffer this, members of the group remain linked to individuals at Pine Ridge long after they leave, as well as to each other. Continuing to gather socially, the group eventually moves beyond shared photo moments (regathering) to deeper reflections of the meaning of their time together on the reservation with the Lakota (reunion).

UNRESOLVED CHALLENGES OF THE FIELD SCHOOL EXPERIENCE

Two concerns about the nursing field school remain open and problematic. One involves effective selection of students for participation. Methods typically used in educational settings to select students (e.g., asking for faculty recommendations, observing students in the classroom or having them produce relevant essays, stories, sets of goals, or personal philosophies) do not accurately predict how individuals handle themselves outside the traditional academic setting or what they are like to live with. Despite discussions and presentations based on previous field schools, most students have little idea about what they are getting into and cannot accurately imagine how field school circumstances will test their flexibility and ability to handle ambiguity over a 6-week period. The students who adapt most comfortably to field school living are generally those who can focus outward from themselves, have relatively broad repertoires of previous Ufe experiences, can gracefully give up comforts (such as air conditioning and shopping mails), value interaction with others and the formation of a community, and have moderate needs for verbalization. An argument can be made, on the other hand, that field school experiences may be most beneficial for those students who do not initially fit those descriptions.

Another ongoing challenge is guidance of the reentry process. Only students who have previously lived in another culture anticipate with any accuracy what the return may entail, and even they do not expect the difficulty they experience on their return from a place that is a part of the United States. Leaving simpler ways of living is part of the transformation required for reentry, but an additional lose involves the dissolution of the caring community formed by the group. The adjustment to more typical classroom and clinical settings involves forfeiting the spontaneity of learning that characterizes the field school situation. One of the values of immersion learning is its sheer pervasiveness. One never knows when or how learning will occur. Imagine, for instance, two students whose task it is to close a gate after late-night stargazing, their laughter ringing through the seamless dark when they realize that they have mastered the gate- but one of them is still inside the fence. Initially, demands to respond to varied and unpredictable situations can be exhausting as well as exciting, but as confidence and competence build over the weeks, they are welcomed and their diminution missed. Perhaps that is the major reason we doubt whether one can ever really go home again.

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