KAREN:  It all sounds like that very one-on-one personal contact with individuals that you're teaching. 

LINDA:  Yes.  Essential.  And so yes, the faculty-student ratio, just as in any school of medicine or nursing, is that you have a very -- the classroom, you know, small-size classroom, very important.  But also then on the clinical, it has to be one-on-one.  You can't supervise four health aides in a clinical situation.
 
And so what we started to do in the early years is to look at not only what our expectations were as to -- and we -- we -- you have to put a score on it, you do have to put a level, and you have to grade it, if we want to call it that.  So that was one piece of the puzzle.

The next one was looking at the use of language.  The first day I came to the -- the health aide training program there, a test was being given and the students were struggling.  And I thought, hmm, I wonder what it is.  And I just sort of just observed. 

And there was a question that said name three sites on the body where an intramuscular injection is given.  What word do you think they had trouble with?  It wasn't intramuscular or injection, it was a four letter word, site.  Now, when we change that to name three places on the body where it would be given, they all knew the answer.

So language was an interesting thing, it was just to not -- not make any assumptions of knowledge, but to really look at the -- how we presented things and the consistency and clarity of language and expectations. 
So from there, as an instructor, my evolution was, then, well, let's see, their notes are just incomplete.  So how can I improve those?  Well, I can write on the blackboard, which is a very common way that teachers try to get better notes for students, especially in the olden days.  And so the difficult -- it was great.  We certainly had better notes for the students, and they had something better to study from, which is the whole purpose, but what I found was, you know, when you're writing on the board and talking and you start to get down a line or two, s that people are now reading, writing, and trying to listen at the same time. 

Well, that's very, very difficult to do when you -- you can listen and write, but you add reading, listening, and writing, and they are reading and you're talking two lines down the board, they really are just sitting there transcribing.  And what a waste of time. 

So my thought is we know that it takes at least three times through information to really learn it.  So I moved in the early '80s to something that we developed in Bethel called Learning Unit Notebooks, which is where we wrote the information down in sentence, outline, sometimes paragraph, but mostly outline format, and the students then were given learning objectives for that section, and at the end of it they had study sections.
 
These notebooks were put together so that when a student came to training, they were given a schedule and a notebook, and the expectation was before class, they were to read and go over the study guide questions. 

That gave them pass one, sort of the first time through the information.  In class, then, we didn't have to lecture.  It was much more of a Socratic dialogue and case presentation and understanding.  And then when they went back through it, that would be their third time. 

And just that clarity of information, it's amazing how test scores changed.  And I mean, it's not rocket science today, but back then, it was pretty revolutionary to give the students the information because I truly believe that the individual, as soon as they sign on to do that job, I believe that they owned the information.  They may not have learned it yet but they own it. 

And I know when I was in school, I always felt like I wasn't ever good enough to learn the information.  The teacher owned it.  They owned it and if I could be -- work hard enough and do the right things that I would somehow be allowed to have that information.  It was a very East Coast -- I don't call it East Coast. 

KAREN:  Western? 

LINDA:  Western, yes.  European model of education.  And my -- my belief is that it really needs to be hands on. 

So we cut the class time in half, we increased hands-on clinical time, we went to something called lab skills and really increased the opportunity to model, to practice, whether it was history, exam, whether it was any of the lab skills, and really started to open the program up into much more of a -- a learning style that was more fitting the Yup'ik. 

And again, that's the culture that I was a part of.  Because the Yup'ik people have honored and believed in education, certainly they could not have survived in that climate if education and learning wasn't a core value of their society.  But it wasn't taught at them, it wasn't in written form, it was more of an observation, practice, doing, and then. 

And again, I had taught at Hopkins for three years, at Johns Hopkins back East with masters-prepared folks, and I found people said, what are you doing teaching health aides, you know, with sixth and eighth grade education. 

And there was no question in my mind that not only did they -- could they learn it, but talk about observant, dexterous, capable individuals who, because they knew the community members, they -- if they said to me, this patient is sick, it wouldn't matter, they knew that the person was sick.  And you'd listen to that. 

And so, you know, here I was teaching folks back East to do episiotomies, which is in the birth process an opening of the vaginal space down through the perineum, and suturing that, and here I was working with health aides in Alaska and suturing because of all of their dexterous skills. 
So I don't -- I don't believe -- I mean, I truly believe that health aides not only can and do learn the information, it's not them, it's us.  It's the trainers and the program that need to be as clear and as organized and precise. 

And also consistent as part of the -- once I became the training coordinator, one of the things I required of the faculty is that you'd have consistency workshops so that as a team because you'd have a faculty of four to six faculty and students, and you know if you have three different ways that you're being shown how to do a skill, you won't learn it.  You -- you need to have a very consistent way. 

So --