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Picture This! Using Photovoice to Facilitate Cultural Competence in Students

Garner, Shelby

doi: 10.1097/CNJ.0b013e31829493a0
Feature: eduaction

ABSTRACT The use of digital images is a prevalent practice in today's society, especially in social media. Photovoice is a qualitative research methodology used to express the experiences of participants from a variety of populations. Photovoice can be utilized as a teaching and learning tool to facilitate cultural competence among undergraduate nursing students.

Digital images are easy to make and popular with today's undergraduate students. Photovoice is a qualitative research method used to express experiences of participants – and it can be used to help teach cultural competence.Supplemental digital content is available in the text.

Shelby Garner, PhD, RN, is a Nursing Assistant Professor at Baylor University Louise Herrington School of Nursing. She has a passion for teaching undergraduate nursing students and employs a variety of teaching methodologies. Shelby is a certified nurse educator (CNE).

Conflict of Interest: The author is conducting photovoice research funded by the Baylor University Undergraduate Research and Scholarly Activities Small Grant Program: The Use of Photovoice to Illustrate Challenges and Supports of Caregivers of the Elderly: A Qualitative Participatory Study.

Accepted by peer review 10/8/12.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article at





The growing phenomenon of personal expression through digital images is clearly seen in social media. A brief look at Facebook or YouTube reveals massive amounts of creative and expressive imagery. Image sharing in social media is so prevalent that nurse educators frequently warn nursing students of the hazards of using this technology in the clinical setting and breaking confidentiality and Health Insurance Portability and Accountability Act (HIPAA) security rules. Although these concerns are warranted, digital photography can be utilized as a teaching and learning tool to assess student perceptions about a concept or an assigned population. In fact, today's undergraduate nursing student is so adept with the use of digital photography on cell phones and in social media that use of images is an excellent fit for the current generation of students.

Although individuals typically take pictures to capture and share a single moment, the study of a collection of photos from an era, culture, or population can be used to glean rich knowledge about societal issues and human behavior (Crandall & Snavely, 2012). Integrating concepts from photovoice research methodology into the classroom can be an innovative method for the facilitation of culturally competent care.

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Photovoice is a method that uses pictures or videos to identify themes and illustrate the needs of a given population, typically one that has been suppressed or marginalized (University of Kansas, 2013). Originated by Wang and Burris (1994) as a community-based participatory research methodology, photovoice has been utilized to illuminate disparities within a community and can be used as an impetus for change. The acronym “voice” in photovoice stands for “voicing our individual and collective experience” (University of Massachusetts, 2011, para 3). Participants using this methodology become co-researchers while making decisions about the direction of the project (Palibroda, Krieg, Murdock, & Havelock, 2009). They are given cameras and asked to take photographs or video of their daily experiences. Participants then attach meaning to their photos by describing what they felt about each photo or what it signifies. Photographs may be literal or abstract, but each is an individual expression used to deliver a message to others. Participants then meet in several focus group sessions, facilitated by the researcher, where they identify and discuss common themes among their photos. Through this qualitative research process, the participants often become empowered as a group to facilitate change among their communities (Palibroda et al., 2009).

For example, a women's health center in Canada conducted a photovoice study with young Aboriginal women living in urban areas. As a group, the women identified themes through photography and “explored issues of violence, racism, poverty, education, and substance abuse” (Palibroda, 2009, p. 24). In addition, the group discussed innovative solutions and examined the role in which local and political policy could create change to improve their lives and the lives of others. Participants were able to present their findings at a national expo to garner attention for their cause.

Although common themes are identified, differences within a population or community also are highlighted in photovoice studies. Cooper and Yarbrough (2010) used photovoice methodology to study perceptions on health issues of birth attendants working in rural Guatemala. Through their focus group meetings they were able to identify differences in perceptions between older and younger participants. Older participants defined illness in concrete, isolated terms such as “diarrhea or headaches” (p. 648) whereas younger participants were more likely to link these events to a cause such as contaminated water (Cooper & Yarbrough, 2010). Summarizing, photovoice is recommended as a research tool for elucidating hard to describe concepts or experiences or hidden feelings and ideas through poignant images.

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Incorporating cultural competence into a nursing curriculum involves a multifaceted approach. According to Campinha-Bacote (2009), obtaining a cultural desire and awareness is among the first steps to becoming culturally competent. Concepts from photovoice methodology can be used to promote cultural desire and assess perceptions of cultural awareness among nursing students about a specific population.

To illustrate how photovoice can develop cultural awareness, undergraduate BSN nursing students who were enrolled in a geriatric nursing class were asked to submit a single photograph of their perception of a challenge or a reward experienced by an elderly person. They also were given the choice to submit a photograph of a support system utilized by the elderly. To encourage abstract critical thinking and avoid HIPAA or other privacy violations, students were asked not to include any photographs of actual people when completing the assignment. The photograph was due on the first day of class to help provide a baseline of student perceptions. Students were told to include a one-sentence description of the challenge, reward, or support depicted in their photograph. The photographs were submitted by email and compiled into a PowerPoint presentation by the instructor. Pictures were grouped according to the assigned categories and a variety of interesting and diverse themes emerged. The most prevalent theme elucidated was challenges related to mobility. Students submitted pictures of wheelchairs, handicap signs, stairs with or without handrails, throw rugs, and other safety hazards. One student submitted a picture of her car, explaining in the caption that over the Christmas holiday, she visited her grandfather who was unable to ride in her car because it was too low to the ground and caused him knee pain when getting in and out. Another prevalent theme was photos submitted of computers and other technology. The students perceived technology to be a challenge for the elderly. Examples of themes depicting rewards included pictures of calendars signifying more leisure time and illustrations of baby clothes with captions related to enjoying grandchildren.

Interestingly, all themes related to rewards were more passive in nature than active. Only 2 out of 44 students submitted images depicting support systems for the elderly, which included pictures of senior citizen centers. Eliopoulos (2010) explained educating older adults on available resources and community support systems is an integral part of the role of the gerontological nurse. Advocating for support systems for the elderly also is an example of adherence to God's Word as stated to, “Stand up in the presence of the aged, show respect for the elderly and revere your God. I am the LORD” (Leviticus 19:32, NIV).

The lack of photo submissions of support systems allowed the instructor to tweak the objectives to emphasize available resources for which the nurse could advocate when caring for the elderly population. The photographs also provided insight into how the majority of the class perceived the elderly. The majority of photographs represented challenges, which was consistent with the students' experiences of caring for the elderly population in the clinical setting and revealed their limited experience with healthy older adults. Gallagher and Carey (2012) also found nursing student perceptions about the elderly were formed from their clinical experiences and were more commonly associated with challenges, such as illness. This knowledge allowed the instructor to emphasize points throughout the course related to healthy aging.

Although photovoice methodology is a qualitative research method, it can be utilized as an innovative tool to assess cultural awareness and weave concepts about a population into the classroom. A sample of images and comments submitted by students is available online as Supplement Digital Content 1 at, and a podcast interview with a student about how photovoice impacted them is available as Supplemental Digital Content 2 at

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When eliciting pictures from students about a population or topic, the instructor should be specific about the objectives. Photographs of individuals or clinical sites should be prohibited unless university approved consent to photograph and publish is obtained. Additionally, students should be warned against copyright infringement and encouraged to only submit their own unique work. Although many students will submit pictures illustrating literal concepts, the most interesting photos often are abstract. The use of photography can enhance critical thinking and stimulate questions about social behavior (Schell, Ferguson, Hamoline, Shea, & Thomas-Maclean, 2009). When the interpretation of the photos involves critical thinking, it will stimulate the most thought-provoking conversations among the students. Whether used to assess student perceptions at the beginning of a course or to evaluate learning at the end of the semester, photography is a relevant tool for incorporating cultural competence into the classroom.

Photography was not available in ancient times but Jesus used vivid visual imagery to help his listeners understand themselves and abstract concepts. He spoke of the birds of the air and hairs on our head to illustrate God's individualized watchful care of his people (Matthew 10:29-31). A lost coin, lost sheep, or a bereaved father longing for his wayward son (Luke 15) demonstrate God's desire to find each of us. A man encountering an enemy needing help illustrates how God asks us to help others (Luke 10). Christ's images were worth a thousand words as he uncovered people's hearts. Nurse educators today can use photovoice to discover hidden concepts and thoughts and feelings of students, helping them begin to understand and desire cultural competence.

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Web Resources

Campinha-Bacote J. (2009). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online Journal of Issues in Nursing, 16(2), 5. Retrieved from
Cooper C. M., Yarbrough S. P. (2010). Tell me--show me: Using combined focus group and photovoice methods to gain understanding of health issues in rural Guatemala. Qualitative Health Research, 20(5), 644–653. doi:10.1177/1049732310361894
Crandall D., Snavely N. (2012). Modeling people and places with internet photo collections. Association for Computing Machinery, 10, 1-15. doi:10.1145/2208917.2212756
Eliopoulos C. (2010). Gerontological nursing (7th ed.). New York, NY: Lippincott.
Gallagher P., Carey K. (2012). Connecting with the well-elderly through reminiscence: Analysis of lived experience. Educational Gerontology, 38, 576–582. doi:10.1080/03601277.2011.595312
Palibroda B., Krieg B., Murdock L., Havelock J. (2009). A practical guide to photovoice: Sharing pictures, telling stories and changing communities. Winnipeg: Prairie Women's Health Centre of Excellence (PWHCE). Retrieved from
Schell K., Ferguson A,, Hamoline R., Shea J., Thomas-Maclean R. (2009). Photovoice as a teaching tool: Learning by doing with visual methods. International Journal of Teaching and Learning in Higher Education, 21(3), 340-352. Retrieved from
University of Kansas. (2013). The community tool box: Implementing photovoice in your community. Retrieved from
University of Massachusetts. (2011). Photovoice. Retrieved from
Wang C., Burris M. A. (1994). Empowerment through photo novella: Portraits of participation. Health Education & Behavior, 21(2), 171–186. doi:10.1177/109019819402100204

    cultural competence; learning, nursing; photovoice; students

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