In response to the American Association of Colleges of Nursing’s (2008) mandate for attention to diversity and increasing globalization, there has been a call for nurses to be prepared to work in a society with an ever-increasing diverse population while providing culturally appropriate care. This mandate has been the impetus for schools of nursing to take students beyond the classroom, often through a global service-learning experience. The National League for Nursing (2012) developed a faculty preparation toolkit for global experiences, underscoring the advancement of global nursing education as a priority.
The global experience offers students an opportunity to provide direct service to individuals, families, and communities in developing countries, often working with marginalized and vulnerable populations. Students are able to apply knowledge of social and cultural issues in globally diverse settings beyond the classroom. In an integrative literature review of study abroad programs for nursing students, Edmonds (2012) identified themes that fostered the development of self-efficacy, cultural competence, critical thinking skills, and the ability to function in unfamiliar surroundings. However, associated costs and time involved in these trips can make them prohibitive, especially “for students enrolled in highly structured academic programs as well as non-traditional students” (Edmonds, 2012, p. 34). Therefore, capturing and measuring student transformation resulting from global service-learning opportunities is critical not only to justify the efforts and cost but also to prepare a culturally competent workforce of nurses who have the ability to serve in a global society. The purpose of this article is to demonstrate the use of photo-elicitation as a qualitative research method that captured transformational outcomes of baccalaureate nursing students who participated in a 10-day global service-learning experience to Nicaragua.
Photo-elicitation has been used for decades primarily in the fields of anthropology and sociology, and more recently, in psychology and education. Although not commonly used in nursing, this phenomenological research method involves having individuals take or select photographs that are representative of their reality and discuss the photographs during interview sessions (Epstein, Stevens, McKeevor, & Baruchel, 2006; Frith & Harcourt, 2007; Plunkett, Leipert, & Ray, 2013). Photo-elicitation has been found to be useful in obtaining data that may deepen understanding of a lived experience that may not always be understood by words alone (Plunkett et al., 2013). The use of photography in various forms (e.g., videotaping and photographs) has been integrated in nursing education to enhance clinical practice, classroom content, and research (Brand & McMurray, 2009; Linz, 2011; Riley & Manias, 2004). A CINAHL® search including the combined terms photo-elicitation, nursing/nursing student, and study abroad/benefits yielded no results in the years of 2004 to 2015. Using the terms photo-elicitation and nursing identified 13 articles; however, there were no reports in the literature using photo-elicitation as a qualitative method in nursing education research to investigate the impact of study abroad programs.
Also known as photo-interviewing and photo feedback, photo-elicitation is “based on the simple idea of inserting photographs into the research interview” (Harper, 2002, p. 13). Bignante (2010) claims that the images, meanings attributed to them, the emotions aroused, and information elicited generate insights different from and beyond those obtained in verbal inquiry. Harper (2002) purports that “exchanges based on words alone utilize less of the brain’s capacity than do exchanges in which the brain is processing images as well as words” (p. 13). The exchange is sharpened by memory that recaptures both feeling and facts of the experience. Thus, photo-elicitation lends itself to be an excellent tool for qualitative research.
To explore the impact of the global service-learning experience in Nicaragua on nursing students’ personal, professional, and cultural development, photo-elicitation was used to evoke responses and insights from students that verbal interviewing alone would not achieve. It was believed that analysis of the photographs, in addition to the meaning ascribed to them, would lead to further understanding of how the immersion experience impacted the development of the participants.
Six female junior- and senior-level traditional undergraduate students, ages 20 to 22, and two male second-degree students were enrolled in the service-learning experience. All of the students were Caucasian and attended the same private university in western Pennsylvania. All but one of the students had traveled previously outside of the United States, were of middle socioeconomic status, and were able to fully fund their trip to Nicaragua. The two second-degree students were ages 26 and 59; their previous degrees were in nonhealth-related fields.
Along with the three faculty investigators, all of the students participated in health care delivery in both urban and rural settings during a 10-day immersion experience. The study was approved by the university’s institutional review board, and all of the students voluntarily signed consent forms to participate.
Data Collection and Analysis
All of the participants took photographs as a natural way of capturing moments, scenes, and events that occurred during their global service-learning immersion experience. The students uploaded their photographs to a password-protected electronic repository accessed only by those who attended the trip. Four weeks after the trip ended, students were asked to select four to five photographs from the repository as a meaningful visual representation of their experience.
Each student then participated in a semistructured interview conducted by one of the three faculty investigators. Students were instructed to bring a copy of each of the selected photographs to the interview. An acronym, SALUD, was created and used to ensure increased organization, consistency, and rigor to the interview process. Investigators documented student responses during the interview. SALUD, the Spanish word for health, was selected to address the following questions with each photograph:
- What is the subjective feeling represented by the photograph?
- What action or attitude is represented by the photograph?
- What leadership or community service is represented by the photograph?
- What understanding of self or others’ life situations is represented by the photograph?
- What determinations or decisions are represented by the photograph?
All of the student responses and pictures were deidentified, and each investigator independently completed an inductive thematic analysis. Responses were compiled under the following headings to correlate with the interview questions: S, subjective feeling; A, attitudes or actions; L, leadership or service-learning; U, understanding of self or others; and D, decisions or determinations. Investigators’ responses then were compared for inter-rater reliability of themes for both photographs and responses. Redundancy of themes was illuminated among all participants, indicating data saturation had occurred.
Through photo-elicitation, photographs selected by the students became a meaningful representation of their experience. Through the process of induction, the investigators identified a progressive evolution of the students beginning with “letting go,” then “embracing reality,” and finally “understanding.” The outcome of this evolution was a profound cultural, personal, and professional transformation.
During the letting go phase, students described the process of leaving what was familiar behind and preparing to embrace new experiences, be open to new thoughts, and find new ways of being. The expressed theme was a need to feel that they were getting away from the comfort of home and from what was familiar. Students commented on the “need to get away and leave behind everything that was familiar, and to have a new beginning.” Accompanying photographs included those taken at the airport prior to departure, thus eliciting leaving what was known and familiar.
After letting go of the familiar, students transitioned to the reality of the situation and life in Nicaragua. When discussing a photograph of a riverbed of garbage, one student stated:
Eventually the reality of the situation around me hit me—I looked around and saw the trash where the kids were playing in, the houses, living conditions, and the reality of being in a different culture.
Another student who was discussing a picture of a poorly constructed metal sheeting and cardboard barrio home said:
Seeing the barrio helped me understand the extent of the poverty...I knew it would probably be different from what I’ve experienced in socioeconomically depressed neighborhoods in the United States, but I was shocked to see the extreme differences.
In the final part of the transformation process, the students began to see past the stark reality of life in Nicaragua—the poverty, the simplicity, and the hardship—and began to understand the strength, enduring spirit, creativity, and the beauty of its people. When discussing a photograph of a man selling mangos, one student stated, “They have a ‘keep at it’ attitude and persistence; Nicaraguans are so resilient.” When discussing a picture of a mural in a cultural museum depicting the history of Nicaragua, another student stated, “They have been through so much, and they are so strong.” Another student, when discussing a picture of a barrio family, noted, “I did not expect it, but families really look out for each other (other families) despite having so many problems of their own.” Other photographs evoked similar comments. One student said, “They do so much with so few resources; they are so creative and think out of the box. There is so much poverty, yet so much beauty in the people.”
Elicitation of Cultural, Professional, and Personal Transformation
The process of transformation affected the students’ understanding of the importance of both cultural competency and its relation to professional practice. Students’ comments included:
- The mural at the cultural museum depicting the history and strife of the country over the past 200 years helped me understand what the Nicaraguan people had been through and how they have endured. Through the mural, I can better understand how such historic events could affect relationships with the United States and other countries. I learned that outsiders like us, as well as political leaders (of all countries), need to communicate to the Nicaraguan people that we appreciate and want to understand their past and respect their values and beliefs.
- Seeing the country and being with the people and getting to know them makes the difference...I finally understand why cultural competency is so important for nurses.
- As nurses, we may teach or suggest a different strategy or action to improve a health problem or reduce a risk, but understanding their culture, their past, and reasons why things are done a certain way needs to be a major consideration.... I will never forget this.
Visual analysis of the photographs according to time sequence revealed that the photographs taken at the beginning of the trip tended to focus on the poverty and harsh reality of Nicaraguan life and overwhelmingly depicted scenes versus people. As the days progressed, the photographs no longer reflected only scenes and negative images, but moved toward more positive aspects of Nicaragua. By the end of the trip, the representative photographs predominantly focused on the beauty of the land and its people. In a land of contrasts and contradictions, the time sequence analysis documented a transformation in the students’ focus from negative to positive that developed as the immersion experience evolved, reflecting a developing appreciation and understanding of Nicaragua and its culture.
Students also experienced a personal transformation and noted feelings of personal self-improvement. One student noted:
I have been shy my whole life. It is very hard for me to open up and talk...I had to put myself out there...it was not as bad as I thought...I made a significant change in myself...I let my guard down for the first time in a while, and it is so much easier to approach people now and start communicating.
Other students’ comments included, “I have more confidence,” “I feel more able to take charge,” and “I am not afraid to do things on my own.” Several students noted that working with Nicaraguan nurses and doctors in a health clinic or as the only non-Nicaraguan with minimal language skill in a family’s home made them realize the importance of “reaching out for help when needed” and the ability to “swallow my pride and ask for help.”
The feeling of personal transformation continued to evolve as students made self-resolutions. Students resolved to have new attitudes and were inspired to change their lives. One student vowed to “have a keep at it attitude,” and another student resolved to “give the best, no matter what you have.” Other students said they would strive to “learn more Spanish,” “have a more loving home,” “not take things for granted,” and “have more respect for my country.”
Some students resolved to live more simply. As one student stated:
Now when I am in the hospital, I need to think before I use anything...do I really need this disposable item? Will it be useful? I even think about not wasting things at home.... You see how little they [Nicaraguans] have, and it makes you not want to waste anything.
The photographs that evoked these feelings of cultural, professional, and personal transformation were as individual as the students who selected them. The range of photographs included a mural at the cultural center depicting the history, hardship, and beauty of Nicaragua; gauze bandages and cotton swabs that were rolled and cut by hand, wrapped in brown paper, and sterilized by the Central Supply staff; a minimally equipped examination room and table at the health clinic; a lit candle at a church; and a family in the barrio. Even when students had the same photograph, the meaning attached was unique to each student. For example, one student chose a picture of a family that represented a resolve to “have a more loving home.” To another, the barrio family represented “giving the best, no matter how little [they] have.” These findings ultimately suggest that transformation is a unique experience for each individual that can be recognized with the use of photo-elicitation.
Although other studies have used qualitative approaches to describe the meaning of an international experience for nursing students (Callister & Cox, 2006; Kollar & Ailinger, 2002; Lee, 2004), the use of photo-elicitation as a research method enabled a deeper, more poignant exploration of the impact of a global service-learning experience. Photographs helped the students to recall, reflect, and reclaim their global service-learning experience while enriching the interview process. This facilitated an understanding of the process of letting go, confronting reality, and coming to an understanding that led to the student outcomes of cultural, personal, and professional transformation. These findings support that global service-learning experiences can help prepare a culturally competent workforce with the ability to serve in a global society and that photo-elicitation can be a useful qualitative research method to capture student outcomes in nursing education and research.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional practice. Retrieved from http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf
- Bignante, E. (2010). The use of photo-elicitation in field research. EchoGéo, 11, 1–17. doi:10.4000/echogeo.11622 [CrossRef]
- Brand, G. & McMurray, A. (2009). Reflection on photographs: Exploring first-year nursing students’ perceptions of older adults. Journal of Gerontological Nursing, 35(11), 30–37. doi:10.3928/00989134-20091001-03 [CrossRef]
- Callister, L.C. & Cox, A.H. (2006). Opening our hearts and minds: The meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing & Health Sciences, 8, 95–102. doi:10.1111/j.1442-2018.2006.00259.x [CrossRef]
- Edmonds, M.L. (2012). An integrative literature review of study abroad programs for nursing students. Nursing Education Perspectives, 33, 30–34. doi:10.5480/1536-5026-33.1.30 [CrossRef]
- Epstein, I., Stevens, B., McKeevor, P. & Baruchel, S. (2006). Photo elicitation interview (PEI): Using photos to elicit children’s perspectives. International Journal of Qualitative Methods, 5(3), 1–11.
- Frith, H. & Harcourt, D. (2007). Using photographs to capture women’s experiences of chemotherapy: Reflecting on the method. Qualitative Health Research, 17, 1340–1350. doi:10.1177/1049732307308949 [CrossRef]
- Harper, D. (2002). Talking about pictures: A case for photo elicitation. Visual Studies, 17, 13–26. doi:10.1080/14725860220137345 [CrossRef]
- Kollar, S.J. & Ailinger, R.L. (2002). International clinical experiences: Long-term impact on students. Nurse Educator, 27, 28–31. doi:10.1097/00006223-200201000-00016 [CrossRef]
- Lee, N.J. (2004). The impact of international experience on student nurses’ personal and professional development. International Nursing Review, 51, 113–122. doi:10.1111/j.1466-7657.2003.00200.x [CrossRef]
- Linz, S. (2011). Photo elicitation: Enhancing learning in the affective domain. The Journal of Continuing Education in Nursing, 42, 393–394. doi:10.3928/00220124-20110823-04 [CrossRef]
- National League for Nursing. (2012). Faculty preparation for global experiences toolkit. Retrieved from http://www.nln.org/docs/default-source/default-document-library/toolkit_facprepglobexp5a3fb25c78366c709642ff00005f0421.pdf
- Plunkett, R., Leipert, B.D. & Ray, S.L. (2013). Unspoken phenomena: Using the photovoice method to enrich phenomenological inquiry. Nursing Inquiry, 20, 156–164. doi:10.1111/j.1440-1800.2012.00594.x [CrossRef]
- Riley, R.G. & Manias, E., (2004). The uses of photography in clinical nursing practice and research: A literature review. Journal of Advanced Nursing, 48, 397–405. doi:10.1111/j.1365-2648.2004.03208.x [CrossRef]