The percentage of older people in the United States is increasing, mainly due to the aging of baby boomers and advances in health care. As of 2014, older adults comprised 15% of the population, with 46 million older adults (over age 65) living in the United States. By 2030, they will likely comprise 21% of the population, or approximately 74 million. Demographics are also shifting. As of 2014, White, non-Hispanic Americans comprised 78% of the older population. By 2060, that number is expected to drop to only 55% of older adults. Although the need is increasing, a deficit of skilled health care workers continues to exist (Rowe et al., 2016). Therefore, it is crucial for nursing students to have learning experiences that prepare them to care for a diverse population of older adults.
Ageism permeates all aspects of society. It is defined as “prejudice or discrimination against a particular age-group and especially the elderly” (Merriam-Webster, n.d.) and is a common form of health care discrimination against older people (Ben-Harush et al., 2016; Kagan & Melendez-Torres, 2015). Allen (2016) posited that ageism discrimination creates such stress in older people that it can adversely affect health and may reasonably be considered a social determinant of disease. Phillips et al. (2015) described a “climate of stereotypes” in which the majority group attributes stereotypes and generalizations to the minority group, but also to aging itself. To be old is to be a minority, whereas gender, culture, and ethnicity further remove the individual from the majority group. To address these concerns, we can look to arts-based educational activities as they have been powerful tools in health care education. Using photography, students engaged in projects that enhanced transcultural skills (Aranda et al., 2015; Baigent et al., 2019; Stupans et al., 2019). Nursing students also used a Photovoice exercise to better understand the experience of living with a chronic illness (Garner, 2014), and Brand et al. (2016) used photo-elicitation to help health care students reflect on images of older adults while receiving care, to increase students' understanding of older people's experience.
The Photo Essay Project
To address ageism and diversity and to bolster interest in working with older people, an arts-based learning exercise was designed using both photo-elicitation and student-created photo essays. Within the pedagogical process, it was recognized that the act of taking photographs makes an experience more real to the student (Byrnes & Wasik, 2009; Stupans et al., 2019). This assignment was inspired by the ethnogerontological nursing model (Phillips et al., 2015) in that students were encouraged to photograph older people within the ethnocultural context of their lives. This educational exercise was also influenced by Allport's (1954) contact theory model that suggested discrimination toward a group could be reduced through contact with a member of the population discriminated against, but only if the contact included equal status, common goals, and common interests. The photo essay project was introduced to an undergraduate Aging and Health in Global Communities course and has been incorporated as part of the course curriculum in two classes for the past two semesters. Seventy-five students have completed the assignment thus far. The gender breakdown of the students assigned the photo essay project was 84% female and 16% male. Their ages were 19 to 23 (47%) and 25 to 53 (53%). Representative of the school of nursing, the classes were diverse, with students identifying as White (44%), African American (30%), Hispanic/Latino (18%), Asian/Pacific Islanders (5%), Middle Eastern (1.5%), and South Asian (1.5%). Part A was previously used in an online course and has been described elsewhere (Linz, 2011); however, it has since been adapted. Part B is newly added to complete this assignment.
The Assignment, Photo-Elicitation, and Photo Essay
Part A Details
Part A was a photo-elicitation exercise in “intensive looking,” assigned to the students in week 3 of their course syllabus. The photo essays shown in part A were created by a faculty member taking photographs of older neighbors. Alternatively, photographs could be found online with a link provided to the students. The first part of the assignment was an exercise in which the student's thoughts and feelings were elicited by the photographs they viewed. Three photo essays, each featuring a different older person, were posted to the classroom's digital platform. The photographs in each PowerPoint® were captioned with a quote, revealing meaningful bits of information about their lives. The photographs had been taken in the older persons' homes and displayed personal objects, such as artwork, family photographs, musical instruments, and pets. The students were directed to view the photographs in the three photo essays in their entirety. Students then were asked to choose the photo essay that they most resonated with, and finally, they had to select their favorite photograph from that essay. They were instructed to stare at it for a full 5 minutes and to write down all the impressions and feelings that the photo elicited. The next step was to write a reflective one-page paper including descriptions of all they had seen, as well as their perceptions regarding the older person in the photograph. Finally, they were instructed to post their paper to the discussion board on the course platform and respond to two other students' posts.
Part B Details
Part B was their final class project to be presented to faculty and peers at the end of the semester. The directions for part B had been thoroughly explained on the first day of class and posted to the digital course platform. The students were asked to find an older person to collaborate with on the creation of a photo essay. As the student photographed the older person, they also had to learn about their lives. Together, they would decide on captions for the photographs taken. The students were encouraged to include ethnic, cultural, and historical information that helped to place the older person's story in the context of their lives. The students selected the seven best photographs to include in a photo essay PowerPoint presentation to be shared with their fellow students as their final class project. Photographic release forms were provided to the students and had to be signed by their photographic subjects and submitted with their presentations.
The students were also asked to submit a reflection essay prior to their PowerPoint presentation to be posted on the discussion board. The students were given the following directions and topics to include in their reflection paper:
- Take a moment to be thoughtful and write about your experience with the assignment, also consider the following questions:
- Did you consider this assignment to be a positive experience? Why or why not?
- While doing the assignment, did anything surprise you?
- How did you feel during the interview?
- How did you feel during the photographic session?
- What changes, if any, have occurred in your perception of older adults? (i.e., What did you think before versus what do you think now?)
- Would you recommend this assignment to others?
The grading rubric for part B included obtaining a signed consent form from the photo essay subject, the creation of a seven-slide presentation with text using direct quotes from the subject, content and quality of the reflection essay posted to the discussion board before the PowerPoint presentation, and the quality of the PowerPoint as presented to the class.
Responses to Part A
The first photo-elicitation essay posted to the students' course platform featured a former educator in her eighties who spoke of her childhood in a Jewish resettlement community, her career as an educator, her marriage, and her opinions on young people. Many students chose one of her photographs to comment on. One student wrote, “What really draws me to this picture is how peaceful and fulfilled she looks…. This is a woman who has endured a lot, but has still come out on top.” The second photo essay featured an older couple in their late seventies who were physically affectionate with each other and still appeared to be romantically in love. The female students especially responded to the relationship between the husband and wife. One student commented, “When I see an older couple in love, it just touches my heart…. They have something so simple.... I feel the elderly now have something we don't, and that makes it very important for us to talk to them.” The last photo essay was of a man in his late seventies with a big smile and full head of white hair who was pursuing a doctoral degree in education, practiced yoga, and walked daily. In the caption on his one somber photograph, he spoke of his time as a hidden child running from Nazis in Europe during the Holocaust, saying he never had a childhood. The students respected his childhood resiliency and admired his current vitality. One student poignantly wrote:
I feel that a man who can continue to laugh at his age is a man that does not have many regrets about life. Looking at his smile with the illuminating sun in the background is a beautiful sight. I feel that the sun is not bringing out the light in him, but the light in his smile is bringing out the sun.
Responses to Part B
To complete part B, the students based their photo essays on the examples they had seen in part A. Many students used a grandparent as their photographic model; however, although their model was known, the students were instructed to discover something that they did not already know. This urban campus has a diverse population, with many first-generation college students and first-generation Americans. Therefore, the photographs reflected the diversity of the student body. The students were able to learn from each other's presentations of older adults from a variety of ethnocultural backgrounds. During the photo essay presentations, the class witnessed older adults in not only western-style attire, but also in African attire and Indian sarees. A photograph of a woman from the Caribbean was shown with her comment that she still preferred to cook in her outdoor kitchen even though her children had built her an indoor one. She posed outside stirring the special soup that her mother had taught her to cook. Another photo essay illustrated the story of an older man as he posed with an ancient foot pedal–operated sewing machine that he had once used to support his family in Hungary. Some photo essays included comments about the obstacles immigrants had encountered and overcome in this country to achieve their life goals, raise children, and flourish in old age.
An older African American woman was photographed in her business office at work and spoke with pride about her career. Several of the men posed with their wives, seated on the sofa while holding their wedding picture. The photograph caption explained how happy they still were so many years later. Many pet companions, especially dogs, were included in the photographs as special companions to the widows and widowers. While women spoke proudly of caring for family and home, men spoke proudly about owning a home, a boat, or a car. Many of the older people discussed their spirituality and love of God and family. The photographic models represented all faiths and ethnicities, as intimate entry to their stories was offered. A woman born in Japan, dressed in a beautiful suit and hat, sat in an elegant living room drinking tea from good china with her pet Husky at her feet, her Yorkshire Terrier on her lap, and spoke of disobeying her parents to come to the United States with her American soldier husband who turned out to be “nothing but a headache.” A Vietnamese man who came to the United States in 1972 met his wife at his first job working on a farm. He is still as happy as the first day they met, and they are shown smiling arm in arm in their modern kitchen. A gray-haired man from Haiti starts his photo essay with an image of his calloused hands and says, “These hands have seen some good and not so good days…. If only these hands could talk!” His essay goes on to show him in his house, his cluttered office, in front of his truck, while proudly speaking of the role religion played in his life. He speaks of his driving force for a better life, how he started as a dishwasher with nothing, and how through hard work he ended up as a skilled trailer mechanic able to raise his children and enjoy his retirement. He ends by saying “God is good!” One student's photo essay starts with an older woman telling the audience through photo captions that she is from Nigeria, she is a war veteran, a mother, a grandmother, and a nurse who helped pregnant women in developing nations all over Africa. A photograph shows her in a beautiful, yellow African print dress with a matching headdress and red stone necklace. She is surrounded by her children and grandchildren, who are also wearing African attire, in shades from pink to striking royal blue. The caption reads that she has four children and 29 grandchildren scattered around the world.
Faculty members who used this learning exercise stated that it had been enthusiastically well-received by the students who found the assignment to be compelling. All but two of the written evaluations of the learning exercise were positive. Of the two who did not have a positive experience, one considered it a “waste of time” and “busy work,” and the other student considered the stress of presenting as the reason to not experience the assignment as positive, stating the “stress of public speaking took the joy from the project.” One instructor stressed that the classroom presentation of photo essays to one another at the end of the semester was a necessary component as “the presentation of multiple photo essays exposes the students to the diversity of aging, and so the presentation is a crucial part of the assignment for overall learning.”
The students evaluated the learning exercise qualitatively in their reflection paper. Their comments did suggest that long-held views on aging had been challenged. Examples of written assignment evaluations included, “It made me more aware to not group ‘old people’ as old and fragile.” Another student wrote about her shift in attitude, “I usually see older adults as a phase that one will no longer have free will and they have to be dependent…but after this class and my time doing the photo essay, my knowledge about aging and older adults changed.” Another student explained, “I loved the photo essay assignment. I think society has a fixed idea of what happens when we get older, and the photo essay assignment proved that wrong.” Viewing all the photo essays during the final PowerPoint presentation offered the students the opportunity to view a variety of older people, each with a unique story. One student wrote, “After hearing everyone present, it helped me to see older adults as individuals with distinct personalities that defy ageist views. It shed new light on what it means to age, and the photo essays were a lot of fun.” When asked if they would recommend this assignment to others, one student showed the need for it when he wrote, “A definite yes, especially because younger adults have this saying ‘live your life now before you get old and senile!’”
Many of the students enjoyed this assignment as an alternative to a paper and reported that it reminded them of older people's worth. In their reflection papers, 58% of students said that they already had a positive perception of older people, whereas 42% noted that they felt their perception of older people had improved as a result of completing the photo essay project. Approximately 80% of this group felt that the experience and the change in their perception would make it easier to care for older people in clinical practice. One of the professors found that it had been helpful to provide the students with interview questions. Students were advised to ask the older person about their culture, their childhood, significant life events, achievements and struggles, and the advice they would give to young people today.
The professor found that adding a younger photograph of the older person to the seven-slide PowerPoint presentation gave a fuller context to the older person's life. Most of the students interviewed their grandparents, although some students interviewed their significant other's grandparents, neighbors, or faculty. The students learned about different cultures through attending the presentations; however, to expose students to a variety of cultures besides their own, it might be helpful to exchange grandparents, so that the students could learn about an older person in the context of their culture more directly. If modified, the assignment could be used for different populations, such as the day in the life of a child or the cultural diversity of families. The assignment could also be used to address stigma by using Allport's (1954) framework with individuals with chronic illnesses or disabilities.
Implications for Nursing
The use of an arts-based photo essay project can bring nursing students and older people together for a meaningful experience that will benefit both parties. Working as equals on a collaborative effort with a common goal fulfills Allport's (1954) criteria needed for discrimination reduction and helps to tell a unique and compelling story about an older person that may counteract long-held discriminatory views. The photo essays produced told stories that were not fixed in a static moment in time, but rather, as Phillips et al. (2015) advised, were presented because of development over the course of a lifetime. The inclusion of images and text displaying cultural and ethnic diversity that occurred in the photo essays also enlightened students to the similarities and differences in the multitude of photo essays that they viewed. The students' experience of witnessing a diverse group of older people could deflect from the “climate of stereotypes” discussed by Phillips et al. (2015). This project also addressed Gallo's (2019) concern, when she advised us to provide rich and rewarding learning opportunities so that nursing students could experience the pleasure and reward that comes from working with the older population, and perhaps ultimately affect their professional choices.
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