Perspectives on Conducting Research in Indian Country

Abstract

Background

Certain research principles, framed within an indigenous context, are helpful guideposts to practice ethical, relevant, and sensitive inquiries. It is essential to further adapt research approaches based on the unique geographical, sociopolitical, and cultural attributes of partnering tribal communities. These adaptations are largely shaped by trial and error.

Objectives

The purpose of this article is to offer the prospective novice nurse researcher lessons that we learned when entering Indian country to conduct research for the first time. As Indigenous and Non-Indigenous researchers, we are not seeking to set down a methodology, but rather, offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting.

Methods

We organized a set of memories and thoughts through a series of semistructured iterative sessions specific to our first encounters as researchers in Indian country. We compiled our written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We have reported what we felt would be the most surprising, frequent, or important information to note.

Results

We identified three overarching themes in our collective experience: orientation and negotiation; situating ourselves and our work; and navigating our way. Subthemes included perceiving ourselves as outsiders, negotiating distance and time realities, relying on the goodness of gatekeepers, shaping research questions per community priorities, honing our cross-cultural and intercultural communication skills, discovering the many layers of tribal approval processes, and developing sensibilities and intuition.

Discussion

Our prior experiences as novices leading research projects in Indian country have produced unique sensibilities that may serve to guide nurse researchers who seek to partner with tribal communities.

An important aspect of successful research in American Indian/Alaska Native (AIAN) communities is knowing the pitfalls and pleasures that may occur in Indian country. These lessons can be learned through experience—sometimes serendipitously—while others can be discovered beforehand if the researcher knows where and how to look. We have all conducted research in Indian country a legal term to mean reservations, Pueblo, and trust lands, as well as certain designated communities. Some of us have conducted community-based participatory research (CBPR), others ethnography, survey work, and Geographical Information Science.

As Robert Wood Johnson Foundation Nurse Faculty Scholars (RWJF NFS) alumni and mentors, we recognize from our diverse experiences in Indian country that there is no “one size fits all” approach to conducting academic-tribal community partnered research. Those of us who conduct CBPR have found that its principles—particularly those that are framed within an indigenous context—are a helpful starting point. Yet, in our experience, it has been essential to further adapt our approaches by learning the unique geographical, sociopolitical, and cultural attributes of the communities with whom we partner. The literature does not address the lessons learned from practicing ethical, nurse-led research, as we set out to do in this paper.

The purpose of this article is to offer prospective novice nurse researchers lessons that we learned when entering Indian country to conduct research for the first time. As Indigenous and Non-Indigenous researchers, we are not seeking to set down a methodology, but rather, offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting. We navigated this “terrain” when we were novice nurse scientists in Indian country, and our intention is to share lessons learned with research colleagues. During our research experiences, we noted many roadblocks, whether cultural, physical, geographic, weather-related, or political. We had to learn what to anticipate, how to build in solutions, how to negotiate to complete our studies on tight timelines, and how to enter societies that were not our own. We were not only entering other cultures, but, in fact, sovereign nations.

Background

For over five centuries since first contact with colonizing Europeans, AIANs have experienced disproportionate disease burden when compared to other Americans (United States Department of Health and Human Services [DHHS], Indian Health Service, 2014). AIANs born today are reported to have a life expectancy that is 5.5 years less than the U.S. all races population, and they continue to die at higher rates than other Americans from a variety of causes, including diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic liver and lower respiratory diseases (Indian Health Service [IHS], 2018; Shiels et al., 2017). This alarming population-level data can obscure the greater disparities experienced in rural and remote areas. For example, life expectancy among the Plains Indians can be 20 years lower, on average, than the U.S. all races population (Moss, 2016).

These health outcomes are largely rooted in economic adversity, poor social conditions, and racial discrimination in the delivery of health services (IHS, 2018; Jones, 2006). Over the past decade, increased efforts to reduce persistent health inequities in AIAN communities have resulted in a substantial number of research projects in which community members are directly involved as equal partners in the research process, contributing to intervention development, implementation, and application of findings (Wallerstein, Duran, Oetzel, & Minkler, 2018). There is an established understanding of the importance of placing CBPR principles within the indigenous research context (LaVeaux & Christopher, 2009) and applying them to academic community partnership development in interventional research (Christopher et al., 2011; Wallerstein & Duran, 2010; Wallerstein & Duran, 2006).

A growing body of literature presents practical applications for researchers who partner with tribal communities in health research. The contributions span a variety of topics, from providing community-level research ethics training (Jetter, Yarborough, Cassady, & Styne, 2015) to creating community-university research liaison positions (Bends et al., 2013), and carefully merging and reconciling Western and indigenous methodologies through collaborative partnerships (Simonds, Wallerstein, Duran, & Villegas, 2013). These exemplars are invaluable to researchers as they provide specific approaches to promote quality partnerships and valuable collaborations to effectively reduce health inequities.

Our Approach

Nurse Faculty Scholars’ Partnerships with Tribal Communities

Through leadership training, mentorship, and funding, the RWJF NFS program supported early-career nurse faculty with diverse research interests. As Indigenous and Non-Indigenous nurse researchers and educators who are committed to partnering with tribal communities to promote a culture of health, we have been enriched from our connections to one another and the informal and formal mentoring that has resulted. To develop this paper, as coauthors we organized a series of semistructured iterative discussion sessions recalling a place and time when we were novice nurse researchers in this work. We asked ourselves, “What do we wish we had known?” and “What lessons did we learn along the way?” We compiled the written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We wrote this paper with one goal in mind: To provide a meaningful discussion of the distinct processes we navigated as novice nurse researchers in the initiation and maintenance of research with tribal community partners and sensitive approaches to troubleshooting along the way. Our intention was to systematically reflect on our experiences, and provide practical perspectives and advice for others who might conduct research in Indian country.

Our Experiences and Lessons Learned

We identified three overarching themes in our collective experience: orientation and negotiation; situating ourselves and our work; and navigating our way (Table 1). We also provide a quick reference guide to some key lessons learned, including practical steps for researchers with aligning rationale (Table 2).

Table 1.

Themes and Representative Exemplars and Quotations.

Themes and subthemes	Representative Exemplars/Quotations
Orientation and Negotiation
Outsiders	• “As a woman, being almost six feet tall, the community members recognized me as Native but knew I was from elsewhere: ‘You are not from here, are you?’ they asked.” (MM)
Distance and time	• “Despite the long miles [often a 4-hour drive, one-way], none of the meetings with the community organization, the tribal college faculty, or the community advisory board should be over the telephone in the formative project stages. The willingness to travel to the project site and meet people is simply a prerequisite for this type of research.” (LL) • “I don’t think people who live in the major urban centers really appreciate the amount of time it takes to do research in tribal areas. I’ve had to drive for hours just to collect one interview, sometimes returning to the same place several times, because the first few times the person wasn’t there, or they didn’t want to talk, or they just weren’t ready to talk. Respecting the participants means honoring their willingness to talk on their timeline, and trusting that they will talk when they are ready.” (EH)
Relying on gatekeepers	• “I did not speak the language, I did not know specifics about the traditional medicine or religious practices, so having a professional trail into the population was key…I did not just show up and say, ‘I would like to do a study with you.’ I staffed NICOA’s Biennial Conference in 1998 in Bismarck, ND, and was introduced to the lead geriatrician for the Indian Health Service (IHS), then based out of [southwest Pueblo nation]. At this time, I had not considered this as a possible site. I continued my ‘clinical’ experience with him the next year in that Pueblo nation, and he introduced me to the Director and Assistant Director of Tribal Elderly Programs.” (MM) • “There were those people who asked me to come and speak to their community groups about cancer, building up my connections and familiarity within the community so when I did come back to ask for help with research I wasn’t a stranger. I wouldn’t be able to do my work now without each of those guides, mentors, and friends.” (EH) • “Individually, each member would have been a fine choice, but the community organizer diplomatically pointed out where former spouses, former political opponents, or factionalized neighbors would be asked to work together. Using this person’s knowledge of community led to convening a group of advisors who were pleased to be working together on a matter of local concern.” (LL) • “Meaningful partnerships start with authentic conversations with the key folks who are able to connect me to other key folks. These conversations are powerful when you stop to consider that new relationships are forming that have the potential to form the foundation of a new research project or program.” (EJ)
Situating Ourselves and Our Work
Research questions born in nursing practice, shaped by community priorities	• “Despite being invited into the community to work on an environmental health project, the community advisory board brought a wide variety of local health concerns to my attention, and, over a period of months, the focus of the work evolved from indoor air quality to influenza and pneumonia immunization uptake and ultimately to pediatric oral health. Members of the CAB came from three communities in a reservation the size of Rhode Island, and the issues they identified as “high priority” reflected the diversity of opinion one might expect. This is another instance where the Tribal Liaison provided invaluable counsel. I was worried about appearing disingenuous to have been invited for one type of project only to work on another. The Tribal Liaison helped navigate that concern and the tribal college faculty who issued the initial invitation became a supporter of the new project.” (LL)
Honing our cross-cultural and intercultural communication skills	“I realize that I am learning as much or more as our tribal partners in this process. For one, I’m learning about how the sociopolitical, cultural, and regional differences impact individual tribes’ engagement in research processes, and I’m learning how to situationally tailor my approaches to align with community needs.” (EJ)
Navigating our Way
Discovering the many layers of approval: Institutional Review Boards (IRBs), Tribal councils, and Tribal Protocols	• “I had to arrange being on the Tribal Governor and Tribal Council’s agenda. Sitting in the room with them, a deer head mounted on the wall with a turquoise necklace staring down at what I was to propose, I remember thinking, ‘no-one back in Houston [doctoral program] has any idea about this’. I presented my proposed work; some people on the council had become familiar with me or my work there…I was given the ‘ok’ and I also sought the cultural leader’s approval as the political leader and cultural represent two different aspects of the community.” (MM) • “The process was to first go meet with the tribal council clerk who managed the agenda along with one member of the community advisory board. The goal of this meeting was to be introduced, explain the request to be placed on the agenda, and get permission to be in telephone contact with the clerk. The last step is important because the tribal council must achieve a quorum to hear the principal investigator (PI). As you would expect with the nation’s governing body, quorum and the agenda can both be dynamic. It is common for the PI and community advisory board member to attend at least a few meetings without the agenda item being called. When the agenda item is called, it is worth noting that the PI may be ushered to the meeting by a Sergeant at Arms and sworn in before testifying. The PI should be prepared to field questions or provide technical information but not be the lone representative of the project at a tribal council meeting. In this case, the process was well worth it. The tribal council members approved the project, praised the work, and thanked the two parties for their shared interest in the well-being of AIAN children.” (LL) • “Even though I knew from attending Native Research conferences that I needed to present my research to the tribe for approval, when it came to actually getting the approval, I found each tribe had their own protocol and the protocol was never obvious. Sometimes it took months of relationship building before I would learn whom I needed to talk to first before I could proceed. In one case, I could go straight to the tribal Chairman’s office. In another case, I needed to talk to the Tribal Health Council first. In yet another, it took almost a year to identify whether it was appropriate to talk to the Tribal Health Council first or to get the permission from the Tribal Clinic Director before going to the Tribal Health Council, and from there I could go to the Tribal Council. By that point, I had enough experience to know that going to the wrong group first would be a violation of protocol and might compromise the whole project. In the end it worked out, but it took a lot of background work to learn the best way to initiate this formal process.” (EH)
Sensibilities and Intuition	• “Starting down the path of research as an American Indian (Chiricahua Fort Sill Apache) nurse researcher, wishing to work in Indian Country felt much like opening a plain brown cardboard box holding a jigsaw puzzle, with no photo to guide my way, no sense of just what I was getting into, and few people there to help fit the pieces together. I’ve walked this path often fueled by sheer determination, the intuitive feeling that the pieces would eventually fit together, and somehow, I would find the tools to know where I was going and when I had gotten something right.” (EH)

Table 2:

Quick Reference Guide to Lessons Learned.

Lesson	Practical Steps	Rationale
Time to begin and conduct research in Indian Country is usually longer than planned and longer than in the dominant culture for the same steps	Need Tribal Council approval or Tribal IRB or Community approval, as well as university, facility, and individual consents just to begin, and then Tribal approval to publish, present; may also need cultural leaders’ approval, may be two different entities	Need to get on the agenda, need to have a quorum, can take months
Distance to reservation or remote community sites can be prohibitive	Will usually have to drive, need GPS (if it works); do not expect street addresses to be mapped	Must figure in time here as well. Bad weather is often a challenge (Plains/Desert), it is rare to be able to fly directly into a site, and it can be hundreds of miles away
Lodging is rarely available on site	Should make solid plans ahead of time. Will often have to find lodging in next closest town	Usually just a few rooms are available in Indian Country
Cell Phones may not work	Check major cell phone service/internet carriers and other service maps. May have to use Wi-Fi calling in some instances or put Satellite Phone in research budget	Calls are frequently not represented on cell phone maps across the Plains, Alaska, other areas of Indian Country
Professional and Personal Liaisons are essential	Partner with a community where you have professional or personal ties or know you must spend many months/year developing these ties prior to entrée	There will be many questions you will have and you will need a trusted resource
Humility and quietness are required	The researcher must enter with humility and spend time listening and observing	These are Sovereign Nations; they have unique norms for political and cultural behavior
Learn about the specific society both before and during the study	With direction from professional and personal liaisons, make efforts to learn about the history of specific Tribe(s) as well as contemporary sociopolitical realities in those communities	Each Tribe is distinct; there may be regional similarities

Orientation and Negotiation

Outsiders

As we individually reflected on our entry into research with tribal communities, we quickly identified one common experience in orientation: Feeling like outsiders. Each of us is a nurse; two of us are Native and two are not. Early on, it became clear that our identities impacted the actions we took to establish and maintain trust, a key tenet in successful research. While both [author] and [author] are Native women, their first nursing research projects took place in communities not their own. For [author], who was partnering with a southwest Pueblo nation, this was over 1,300 miles away from her tribal community in North Dakota. [Author] recalls: “Being almost six feet tall, the community members recognized me as Native but knew I was from elsewhere: ‘You are not from here, are you?’ they asked.” From her experiences, [author] recalled, “I had never set foot in that community and knew shamefully little about it; it was in a part of the country I had never seen.” [Author] shared that she grew up in a rural town in Oklahoma situated in and near surrounding tribal nations; however, being a non-Native woman initially seemed, in her mind, to be a barrier. As novice nurse researchers, we each acutely perceived ourselves as outsiders. We know now that it effectively served to heighten our vigilance as we interacted with community members and leaders, and, importantly, it helped us recognize that there was value in the typical, slow pace of research processes. This pace provided the time that was necessary to demonstrate our trustworthiness and genuine care for the communities with whom we have partnered.

Distance and time

Our reflections as novices highlighted another key logistical lesson that we learned in building relationships with individuals and families in regionally diverse tribal communities. We each learned to anticipate and eventually plan for geographic, time, and cost-related challenges that were inherent in our work. We also quickly learned the value of being physically present, from the earliest team planning meetings to poststudy debriefing meetings with participants and communities (see Table 1).

[Author] recalled making the trip to her clinical site frequently, an action that proved invaluable in providing opportunities for the elders to recognize that she was a “Native nurse helping out.” Importantly, [author] spent a full year developing relationships in a southwest Pueblo nation prior to initiating data collection. Chuckling, she shared, “I guarantee none of my fellow doctoral students were flying long distances, renting a car, and driving down the remote, often-under-construction roads to meet with community members.” [Author] learned to rely on an “intuitive sense of navigation,” recalling that, frequently, individuals from the community were not where they said they would be or when they had agreed to be there. Along with long-distance challenges, we also learned to value patience as a required virtue. [Author] recalled one situation in which peacefully waiting eventually gained her time with a busy tribal leader. After sitting for several hours in a busy hallway, she was invited in for a brief meeting with the tribal official, during which she was invited to present her research. He signed the required letter of support, and she could move forward with her project. Afterward, she reflected on the importance of waiting quietly; had she demanded to meet the official at the appointed time, she would never have been granted permission to speak with members of that tribal community.

Relying on gatekeepers

A common experience among the four of us was our reliance upon the goodness of gatekeepers, mentors, and often strangers to gain traction in tribal communities. A willingness to be authentic and to openly recognize our own ignorance was frequently the foundation undergirding a long-term research relationship (Table 1).

In [author’s] experience, her first invitation to work on a project with an AIAN community came after successfully completing research in majority-culture communities. [Author] shared that her opportunity to partner with tribal communities in New England resulted, in part, from her team’s prior positive track record of partnership with a tribal community in the southcentral U.S. Frequently, the gatekeepers (ranging in role from tribal liaisons, community organizers, office receptionists, clinic nurses, community health workers to study coordinators who are elders or other individuals with a deep knowledge of the community and its people, culture, and history. We learned the value of deference to the gatekeeper early and in all matters, not simply on those issues that the nurse researcher thinks have cultural or research significance. [Author] told a story that illustrated the value of this investment. She once presented the tribal liaison with a list of numerous potential candidates to populate a community advisory board and quickly learned the limits of her perspective and the value of the gatekeeper’s (Table 1).

Situating Ourselves and Our Work

Research questions born in nursing practice, shaped by community priorities

Three of us ([authors]) initiated projects with a tribal community during our doctoral studies. Although our practice areas varied, we all felt that these research projects were enriched because our questions grew organically from our clinical experiences. In our various areas of research (i.e., [areas]), we noted that very little had been written or described about our phenomena of interest, and we determined that qualitative or mixed-methods work would be the best approach to take. Because of excellent mentorship, we prioritized hearing and heeding voices from the community and aligning our own project goals with community goals. While each of us benefitted from the patience and generosity of AIAN community members, we all affirm that the goal is to serve rather than burden in the design and execution of nursing research and public health projects. [Author] shared a story that illustrates how research priorities can shift when community members’ voices are heeded (Table 1).

Honing our cross-cultural and intercultural communication skills

[Author] admitted that in the first weeks of engaging in CBPR with a local tribal community, she found herself benefitting from cultural skills she did not know she had. She described these as, “being deferent to those elder to myself, regardless of station in life; using an intuitive sense of navigation because reservation directions are never based on road signs or mileage markers; always following through; and listening more and talking less.” As novices, we found that humility and being open to personal growth are requirements of engaging effectively in partnership with diverse tribal communities.

Navigating Our Way

Discovering the many layers of approval: Institutional review boards (IRBs), tribal review boards, tribal councils, and tribal protocols

Nurses who wish to partner in research with tribal communities should know there are 573 federally recognized tribes in the U.S. (Bureau of Indian Affairs, 2018). There are also state-recognized tribes, landless tribes, and some that are both (Moss, 2016). It is essential that novices begin to understand the political designation of their proposed partnership area. We learned that one of the most time-intensive aspects of our research was gaining approvals from governing bodies including university, tribal and service area IRBs, and securing resolutions of approval from tribal councils. While time-consuming, frequently these processes allowed for cultural immersion in addition to addressing ethical considerations. Although the steps to completing the tribal resolution process may be unique to each community, each of us has experienced some variation of [authors’] accounts of these steps in the research process (Table 1).

Sensibilities and intuition

In describing her experience as a novice nurse researcher in Indian country, [author] evoked an image of a jigsaw puzzle with no photo to guide the way (Table 1). This metaphor resonated with the four of us in our own prior experiences, and reminded us of the sensibilities and intuitions that have emerged over time, often from learning things the hard way. For example, we discussed that using grant funds to benefit the community can have a ripple effect. In one community, there might be two locally operated grocery stores, but only one might be locally owned. Purchasing gift cards from the grocery that is locally owned may be a small gesture toward the equitable distribution of resources appreciated by community members. Indeed, we owe a debt of gratitude to community partners who have served as guides in helping us navigate uncertain paths and develop sensibilities along the way.

Discussion

Our observations reflect elements of the journey that Holkup and colleagues (2009) described in their cross-cultural conceptual model of “negotiating the three worlds” of academia, nursing science, and tribal communities. Based on the diverse experiences of academic-tribal community research teams in Montana and Wyoming, Holkup et al. (2009) concluded that the values of relationship and reciprocity were crucial to conducting successful research. Accounting for the unique political milieus of academic institutions, nursing science, and tribal communities, the authors suggested that meaningful research relationships can form at the intersections of these three spheres when complex negotiations are approached with skill and care (Holkup et al., 2009). This resonates with our own reflections. By organizing our practical examples into the three themes of orientation and negotiation; situating ourselves and our work; and navigating our way, we illustrate processes frequently encountered by novice nurse researchers in “negotiating the three worlds.”

Conclusion

In sharing perspectives, we gained through lessons learned, we hope to assist other nurse researchers to navigate these three worlds in a way that promotes the health of AIAN elders, women, children, families, and communities and advances nursing science simultaneously.