Benner, Sutphen, Leonard, and Day (2010) called for teaching toward “multiple ways of thinking” (p. 85) to foster a sense of salience and clinical and moral imaginations in nursing students. With this encouraging call to think about how nursing education is imparted, the traditional link between didactic and clinical practice must be considered. The general teaching practice in nursing is that students in didactic courses are exposed to the conceptual underpinnings applied by nurses working in various clinical settings. In community health nursing, some of the conceptual underpinnings are population health, epidemiology, social justice, health inequities, and cultural humility. Ideally, these concepts are applied in the community clinical setting while the students are in their clinical rotations. However, the connection between didactic and clinical practice may not have a strong articulation. In addition, a content-laden didactic course, such as Community Health Nursing, may not achieve the goal to improve critical reasoning skills in the clinical setting (Tanner, 2010). One of the ways to strengthen the link between didactic course content and clinical experience is through the incorporation of experiential learning. Experiential learning is the process whereby the creation of new knowledge takes place through experiences that transform previous perspectives (Kolb, 1984).
The purpose of this article is to describe the adaptation and incorporation of a qualitative research method—photovoice—as a strategy to enhance the traditional windshield survey and key informant interviews in students’ community health assessment project. The authors’ goal was to use photovoice not as a research method but as an experiential learning strategy that strengthens the connection between the didactic and clinical in the Community Health Nursing course.
Photovoice as a Research Method
Photovoice is a research method that applies Paulo Freire’s critical dialogue theory (Freire, 2000, 2005; Shor & Freire, 1987), where research participants create photographic images that allow for participant-generated narratives about community life and needs. Through the medium of photographs taken around the community, photovoice facilitates communication around the topic of change among the participants, researcher(s), other community members, and policy makers (Freire, 2005; Wang & Burris, 1997). Although the photographs taken around the community by the participants are interesting, it is how the community members converse and tell the story about their community that is the most important. This particular research method allows the participants to explain how the community environment influences their health behaviors and shapes their lives.
Adaptation of Photovoice Into a Community Clinical Experience
On the basis of Freire’s critical dialogue theory (2000, 2005), the authors adapted photovoice as a teaching strategy for the Community Health Assessment course. The goal was to facilitate a critical dialogue among students, clinical faculty, and community members and provide students with an in-depth experiential learning activity. The critical dialogue helps students to explore and apply community health nursing concepts taught in the didactic course. Through experiential learning activities, students acquire a sense of salience and clinical and moral imaginations (Benner et al., 2010), which further develop their skills for community health nursing practice (Shor & Freire, 1987). As community health nursing faculty, the authors view this sense of salience as the ability to see the whole picture in a community clinical situation and to discern the priorities from the nonpriorities. Clinical imaginations occur when students integrate the learning that takes place in the community didactic and clinical experience and imagine how they can apply the new information to other clinical courses and their future practice as a nurse. The authors believe that moral imaginations take place when students develop an ability to quickly make connections with community members and act within a framework of social justice, cultural humility, and compassion when developing and delivering community-based interventions.
Incorporating Photovoice in a Community Health Nursing Clinical Experience
Photovoice was incorporated into the community windshield survey and key informant interviews, which are part of the community health assessment project. The aim of the community health assessment project is to teach students how to apply the nursing process when delivering care to a population or aggregate in a community (Anderson & McFarlane, 2010; Nies & McEwen, 2015). Students first assess the community by completing a windshield survey, conducting key informant interviews, and gathering descriptive data, such as demographics and morbidity and mortality rates. From the assessment, students analyze the information, develop a priority list of areas that need improvement, and validate this list with the community members. After validation, the students and faculty, with the guidance of the community members, develop an intervention to address the community’s area of concern. The incorporation of photovoice into the community health assessment activities was divided into the following three phases: (a) taking the photographs as part of the community windshield survey, (b) having a critical dialogue between students and faculty about the photographs, and (c) students sharing the photographs with community members during key informant interviews. The description of the incorporation of photovoice into the community health assessment follows.
Taking the Photographs as Part of the Community Windshield Survey. A community clinical group of 10 nursing students in the Bachelor of Science in Nursing program was divided into smaller groups of three to four students. Each smaller group was provided with a disposable camera and assigned a census track that served as a geographical area of focus for the group’s windshield survey. The use of disposable cameras prevented students from uploading images on social media Web sites, thus minimizing the potential of breaching the confidentiality and privacy of community members (National Council of State Boards of Nursing, 2011). The students were told not to take photographs of individuals without their permission. In addition, the students were provided with institutional talent release forms for those individuals who did give permission. The groups were encouraged to take photographs of things that were surprising and unexpected to them during the windshield survey in the community. The students were given a form on which to provide a title and brief description for each photograph they took. The group returned the disposable cameras to their clinical instructors at the end of the clinical day. The photographs were developed and organized to ensure that each group of photographs corresponded to the correct title and brief description provided by the groups.
Student and Faculty Critical Dialogue About Photographs. After the photographs were developed, the students were provided with the photographs and their title and brief description forms during the following clinical day. The students were given 30 minutes to sort through the photographs and find five photographs that represented the community’s needs and five photographs that represented the community’s strengths. After time was up, each group presented their selection of photographs and the rationale for the selection to the other group members. In this verbal presentation, the students discussed their perceptions of what the photographs showed.
To deepen the conversation, the instructors used Socratic questions to engage students in dialogue (Paul, 1990). For example, several photographs were of drawings on street walls (Figures 1–2). Some students described it as art, whereas others said it was graffiti. To promote a critical dialogue, the authors posed the following Socratic questions: (a) “What is the role of art in a community?” (b) “What is the role of graffiti in a community?” (c) “When does graffiti turn into art?” and (d) “When does art turn into graffiti?” Those questions started a dialogue where students talked about the positive influence that art can have on a neighborhood’s sense of ownership and belonging, how art can serve as an expression of community ethnic pride, how graffiti may change the perceptions of safety in a community, and how graffiti served to mark boundaries between rivaling gangs in the community.
Photograph of a mural depicting ethnic pride.
Photograph of wall graffiti.
Students Sharing the Photographs With Community Members. Finally, the students shared the photographs with community members from one of the community centers during the key informant interviews. The authors suggested that the students use the following script when sharing the photographs with community members:
Our teacher had us take photo[graph]s of the community so we can better understand where you live. If you do not mind, we would like to share with you the photo[graph]s we took and have you tell us what you see.
This sharing of photographs and the ensuing dialogue with key informants provided the students with a contextual insight of the community, which they would not have experienced if they had not had the photographs.
For example, the students had several photographs of homes with metal bars on the windows (Figure 3). During the critical dialogue about the photographs, the students told the faculty that they viewed the metal bars on windows as trapping people inside and being hazardous in the event of a fire in the home. However, the students’ perception changed when they shared the photographs with the key informants. The key informants explained that the metal bars on the windows of the homes were put in place to protect the families and their possessions from outside intruders. The key informant feedback provided the students with a new context-based perspective on the rationale for placing metal bars on the windows of homes. This critical dialogue also led to a discussion among the students and key informants about the importance of having an emergency plan in place for the residents of the homes with metal bars on the windows in case a fire occurred. In collaboration with the students, the key informants developed a community-based intervention to disseminate information on evacuation and procedure plans in case of home fires, especially those homes that had metal bars on the windows.
Photograph of a house with bars on the windows.
Results and Student Feedback on Photovoice
At the end of the semester, students provided written feedback about the inclusion of photovoice as a teaching strategy for the community health assessment project experience. First, the students liked that they could use the photographs as a reference point during their critical dialogue and when developing their community nursing intervention. For example, one student shared:
I liked having the photo[graph]s when we talked in the clinical conference. The photo[graph]s helped us remember things that we could use when coming up with an intervention that would “stick” in the community. We were also able to refer to them later when writing the community paper.
Second, students liked that the photographs allowed them to have a holistic view of the community. One student explained:
It helped me see the bigger picture of the community and the context of things. I was able to pay close attention and discuss different details of what I saw, for example, the bars on the windows.
Finally, one student described why she did not like the activity: “It took up a lot of our time, and driving around felt like it was never going to end.” That type of statement may indicate a lack of understanding of the purpose of the activity. Perhaps using Socratic questioning on the use of photovoice during community assessment activities would increase the understanding of its purpose.
Although a range of articles describe photovoice as a qualitative research method, there are few instances where photovoice is used as a teaching strategy with undergraduate nursing students (Garner, 2014; Leipert & Anderson, 2012). Garner (2014) used photovoice in a medical–surgical didactic course to help students reflect on the challenges experienced by patients with chronic illness. Leipert and Anderson (2012) used photovoice to help students explore rural nursing practice, with the purpose of increasing interest in rural nursing as a career.
This article describes the adaptation and incorporation of photovoice as a medium to provide students with an enhanced community health nursing clinical experience. In a typical community health nursing clinical course, knowledge about community health concepts is transferred from didactic faculty to student. During the clinical sessions, students have the opportunity to witness and discuss the application of those concepts. However, the discussion in the clinical experience can be static, causing students to lack the ability to apply the concepts. For example, the discussion on prioritizing health needs and evaluating strengths and weaknesses in the community becomes a list to consider, rather than a living web of structural and environmental facilitators and constraints for community health. The use of photovoice moves this static conversation to encourage students to consider the voice of the community by looking through the lens of a camera.
The use of photovoice allows students to develop a sense of salience when prioritizing community interventions. The application of clinical and moral imagination occurs when students integrate the voice of the community to develop community-based interventions. Using the photographs to think about community needs and strengths encourages the students to create a dialogue with each other, faculty, and community members about potential solutions. Realizing that different points of view exist can strengthen such dialogue and provide creative and innovative solutions to community problems.
Photovoice allows students to consider that people are embedded not only in their families but also in their communities. Therefore, any community nursing intervention must include the residents in the dialogue to arrive at sustainable solutions. The authors suggest that incorporating photovoice not only in clinical experiences but also in the classroom is a way to enhance didactic teaching and learning, as noted in the medical–surgical course study by Garner (2014). The photo-voice medium can be used creatively to provide students with an enjoyable activity that will lead to reflection and critical thinking about their practices in nursing.
- Anderson, E.T. & McFarlane, J.M. (2010). Community as partner: Theory and practice in nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
- Freire, P. (2000). Pedagogy of the oppressed. New York, NY: Bloomsbury.
- Freire, P. (2005). Education for critical consciousness. New York, NY: Bloomsbury.
- Garner, S.L. (2014). Photovoice as a teaching and learning strategy for undergraduate nursing students. Nurse Education Today, 34, 1272–1274. doi:10.1016/j.nedt.2014.03.019 [CrossRef]
- Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall.
- Leipert, B. & Anderson, E. (2012). Rural nursing education: A photovoice perspective. Rural and Remote Health, 12, 2061.
- National Council of State Boards of Nursing. (2011). White paper: A nurse’s guide to the use of social media. The Journal of Practical Nursing, 61(3), 3–9.
- Nies, M.A. & McEwen, M. (2015). Community/public health nursing: Promoting the health of populations (6th ed.). St. Louis, MO: Elsevier.
- Paul, R. (1990). Socratic questioning. In Binker, A. (Ed.), Critical thinking: What every person needs to survive in a rapidly changing world (pp. 269–298). Rohnert Park, CA: Sonoma State University.
- Shor, I. & Freire, P. (1987). What is the “dialogical method” of teaching?The Journal of Education, 169(3), 11–31.
- Tanner, C.A. (2010). Transforming prelicensure nursing education: Preparing the new nurse to meet emerging health care needs. Nursing Education Perspectives, 31, 347–353.
- Wang, C. & Burris, M.A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24, 369–387. doi:10.1177/109019819702400309 [CrossRef]