Beyond the visual and verbal: Using participant-produced photographs in research on the surroundings for care at the end-of-life

Show and Tell: Photography and Storytelling to Better Understand the End-of-Life Experience of Families in the Intensive Care Unit

End-of-life in the Intensive Care Unit (ICU) is common, costly, and can contribute to negative health outcomes for bereaved family members. Insufficient understanding of the family experience results in poor quality, highly variable care riddled with deficiencies including effective identification and application of evidence-based clinical interventions. Successfully managing the multitude of transitions, for example changes in family role or personal identity requires creative practice guided by theory. This project supports the feasibility of using peri-mortem photographs captured by family members with story-telling and a standardized measurement of grief to explore the family experience of end-of-life in the ICU. Project findings reveal shared experiential themes and emphasize the value of photography and storytelling as meaning-making interventions for families. Further study to generalize findings and develop additional preventative and therapeutic interventions at and beyond end-of-life in the ICU is needed to better meet family needs and improve their health outcomes.

A Problem of Gender Representation: Adapting the Bechdel Test to Evaluate the Social Media Presence of Radiology Residency Programs

RATIONALE AND OBJECTIVES

Social media serves as recruitment tools for residency programs, allowing programs to "brand" themselves in an era of virtual interviews. For female applicants, viewing their gender represented on Instagram may influence their pursuit of a program. Our study's goal is to quantify how female-presenting professionals are represented on radiology residency (RR) Instagram pages, as these are increasingly important platforms for resident recruitment.

MATERIALS AND METHODS

The Bechdel test is a well-known measure of the representation of women in fiction that requires at least 2 women speak to each other about a topic other than a man. We modified this test to evaluate the portrayal of female-presenting professionals on public Instagram galleries of RR programs. For a photo to pass our test, female-presenting persons are shown physically together, without male-presenting professionals, and in a professional setting. To compare gender depiction, a Male Bechdel Test was also used. RR Instagram pages were identified using the Fellowship and Residency Electronic Interactive Database Access (n = 87) and examined with an adapted framework approach to count female and male-presenting individuals in 1044 images. Results were assessed using paired t-tests and a chi-square with McNemar's test.

RESULTS

Approximately 50% of the RR Instagrams passed the Male Bechdel Test while only 21.3% passed the Female Bechdel Test, a significant difference in gender representation (χ²(1) = 13.255, P = 0.022). Paired sample t-tests revealed that RR Instagram pages are significantly more likely to feature male-presenting professionals in a professional setting (P < 0.0001), feature them with other male-presenting professionals (P = 0.001), and feature them without female-presenting professionals (P = 0.003).

CONCLUSION

Our results suggest female-presenting radiologists are under-represented on the Instagram profiles of RR programs. While this reflects the dearth of females in this field, programs may improve gender inclusion by more prominently displaying females on social media. This may assist in recruiting minority applicants.

Designing the physical environment for inpatient palliative care: a narrative review

BACKGROUND

It is essential that the physical environments in which inpatient palliative care is provided support the needs of patients and the facilitate the multidimensional delivery of palliative care. This review aims to identify the features and characteristics of inpatient palliative care environments that enhance or detract from the patient experience; and identify opportunities for progress within this field.

METHOD

Three databases were searched: MEDLINE (1946-2020), PsycINFO (1806-2020) and CINAHL (1937-2020). Articles were screened by title and abstract with included studies read in full for data extraction. Data synthesis involved thematic analysis informed by the findings of the included literature. Inclusion criteria were studies with empirical methodology examining adult palliative care in the hospital, hospice or nursing home environment. Studies that examined palliative care delivered within the emergency department, ICU or within the home were excluded, as were those related to paediatric palliative care.

RESULTS

Four main themes were identified: the provision of privacy, facilitating interactions with family, facilitating comfort through homeliness and connections to nature.

CONCLUSIONS

The board acceptance of single rooms as the preeminent design solution for supporting privacy, dignity and family interaction, alongside current conceptions of homeliness that typically focus on matters of interior design, are limiting possibilities for further design innovation within palliative care settings. Research that investigates a broader set of design strategies through which the built environment can support care, alongside enhanced interdisciplinary collaboration, could positively contribute to patient and family experiences of inpatient palliative care.

The viability and appropriateness of using visual methods in end of life research to foreground the experiences of people affected by financial hardship and deprivation

BACKGROUND

Visual methods have been used extensively in social research to explore people's experiences of structural disadvantage. This indicates that they may provide a useful research approach to understanding equity-related concerns within palliative care. However, little has been published regarding the use of visual methods with people at the end of life.

PURPOSE OF THE PAPER

In this article we draw on our experiences of using visual methods to illuminate the end of life experiences of people experiencing financial hardship and deprivation in Scotland's largest city.

EVIDENCE USED TO SUPPORT THE INFORMATION PRESENTED

We present evidence from the published literature, as well as our own experiences of using visual methods to explore dying at home for people experiencing financial hardship and deprivation. Our analysis draws on two specific visual methods: photovoice and professional photography. Photovoice is a participatory visual method which involves enabling participants to take and discuss their own images and present them to different audiences to try to enact social change. We report our experiences as researchers, as well as those of our participants and recruitment partners.

KEY LEARNING POINTS

To successfully use visual methods, researchers need to invest significant time and resource in building a strong rapport with participants. There are also key ethical, practical and representational challenges to consider. A participatory framework should be adopted which ensures agency for participants in terms of image creation and public dissemination. Participants reported value in using visual methods in terms of legacy building and self-representation. Using photovoice (insider's view) and professional photography (outsider's view) together offered complementary perspectives, enabling a rich layering of stories and meaning. Our findings indicate visual methods can illuminate aspects of the end of life experience not captured by other research methods.

Spirituality During the COVID-19 Pandemic: An Online Creative Arts Intervention With Photocollages for Older Adults in Italy and Israel

The present study aimed to examine how expressions of spirituality were stimulated and reflected in an online creative arts intervention for older adults during COVID-19 lockdowns. The online process focused on the creation of digital photocollages together with narrative elements of dignity therapy. Twenty-four Israeli and Italian community-dwelling older adults aged 78–92 participated in a three-session online intervention involving the production of three photocollages. The visual and verbal data (participants’ chosen photos and photocollages, and transcripts of the sessions) were qualitatively analyzed within an abductive framework. Four themes were generated, representing the four domains of spirituality that were stimulated by and expressed in the process: (1) Connectedness with the self, (2) connectedness with others, (3) connectedness with the environment, and (4) connectedness with the transcendent. The findings show how photographs can serve as projective visual stimuli which elicit personal content through spontaneous thinking, and they reveal the multifaceted nature of spirituality, wherein each domain nourishes the others. Overall, the findings illustrate how creative arts intervention guided by the tenets of dignity therapy can contribute to the spiritual care of older adults during periods of social isolation, or to the spiritual support provided in palliative care.

The rationales for and challenges with employing arts-based health services research (ABHSR): a qualitative systematic review of primary studies

Health services research (HSR) is an interdisciplinary field that investigates and improves the design and delivery of health services from individual, group, organisational and system perspectives. HSR examines complex problems within health systems. Qualitative research plays an important role in aiding us to develop a nuanced understanding of patients, family, healthcare providers, teams and systems. However, the overwhelming majority of HSR publications using qualitative research use traditional methods such as focus groups and interviews. Arts-based research-artistic and creative forms of data collection such as dance, drama and photovoice-have had limited uptake in HSR due to the lack of clarity in the methods, their rationales and potential impacts. To address this uncertainty, we conducted a qualitative systematic review of studies that have employed arts-based research in HSR topics. We searched four databases for peer-reviewed, primary HSR studies. Using conventional content analysis, we analysed the rationales for using arts-based approaches in 42 primary qualitative studies. We found four rationales for using arts-based approaches for HSR: (1) Capture aspects of a topic that may be overlooked, ignored or not conceptualised by other methods (ie, quantitative and interview-based qualitative methods). (2) Allow participants to reflect on their own experiences. (3) Generate valuable community knowledge to inform intervention design and delivery. (4) Formulate research projects that are more participatory in nature. This review provides health services researchers with the tools, reasons, rationales and justifications for using arts-based methods. We conclude this review by discussing the practicalities of making arts-based approaches commensurable to HSR.

Photo-experiencing and reflective listening: A trauma-informed photo-elicitation method to explore day-to-day health experiences

Despite the promise of photography in research, few methods offer a guide to leverage this medium in conjunction with experience sampling to facilitate individual reflection while capturing the experiences of participants as they interact with their social world. The purpose of this paper is to introduce a new photo-elicitation method to add to the photography research repertoire, Photo-experiencing and Reflective Listening (PEARL). PEARL leverages the benefits of experience sampling, mindful self-awareness, and trauma-informed interviewing to document daily health experiences. After engaging in an at-home photography activity, participants meet for a one-on-one interview to share and cluster their photographs to discuss key themes and needs going forward. Using a study aimed to understand the recovery experiences of survivors of sexual violence, we illustrate how PEARL can be applied to study a population of interest. The products developed through PEARL provide rich opportunities for analysis, dissemination, story amplification, and action, making it a research method helpful for those interested in improving health equity and catalyzing social change. Because of the high satisfaction voiced by the participants of this approach, PEARL shows promise as a therapeutic data collection method, where the participants leave with some benefit through new awareness gained.

Using Cards to Facilitate Conversations About Wishes and Priorities of Patients in Palliative Care

To avoid discomfort, health care professionals may hesitate to pursue conversations about end of life with patients. Certain tools have the potential to facilitate smoother conversations in this matter. The objective was to explore the experiences of patients in palliative care in using statement cards to talk about their wishes and priorities. Forty-six cards with statements of wishes and priorities were developed and tested for feasibility with 40 participants, who chose the 10 most important cards and shared their thoughts about the statements and conversation. Data from individual interviews and field notes were analyzed using content analysis. One category describes practical aspects of using the cards including the relevance of the content and the process of sorting the cards. The second category describes the significance of using the cards including becoming aware of what is important, sharing wishes and priorities, and reflecting on whether wishes and priorities change closer to death. The cards helped raise awareness and verbalize wishes and priorities. All statements were considered relevant. The conversations focused not only on death and dying, but also on challenges in the participants' current life situation. For the most ill and frail participants, the number of cards needs to be reduced.

Why Is Airline Food Always Dreadful? Analysis of Factors Influencing Passengers’ Food Wasting Behaviour

Food waste is emerging as a global issue and has been recognised in the Sustainable Development Goals with a specific target to halve per capita global food waste at consumer levels and reduce food losses by 2030. Research on food waste has been neglected particularly in the aviation sector. The International Air Transport Association reported that 5.7 million tonnes of cabin waste was generated on airlines, up to 80.5% of which was leftover food and beverages. The exploration of passengers’ food wasting aims to provide insights for tackling the airline food waste problem. To address this issue, this research investigated the in-flight catering experience of 19 passengers from 21 full-service flights. Qualitative research techniques have been applied to analyse passengers’ food-wasting behaviour by collecting participant-produced photographs and completed questionnaires concerning food-related behaviour. This research identified key factors associated with passengers’ food wasting behaviour by adopting Design for Sustainable Behaviour approaches. Four types of factors were found to influence onboard passenger waste, these were normative, habitual, intentional and situational factors. This research indicates that behavioural change interventions need to incorporate the power of social norms to prevent food waste.

Introducing the trajectory Touchpoint technique: a systematic methodology for capturing the service experiences of palliative care patients and their families

Background

Evaluation of palliative care services is crucial in order to ensure high quality care and to plan future services in light of growing demand. There is also an acknowledgement of the need to better understand patient experiences as part of the paradigm shift from paternalistic professional and passive patient to a more collaborative partnership. However, while clinical decision-making is well-developed, the science of the delivery of care is relatively novel for most clinicians. We therefore introduce the Trajectory Touchpoint Technique (TTT), a systematic methodology designed using service delivery models and theories, for capturing the voices of palliative care service users.

Methods

We used design science research as our overarching methodology to build our Trajectory Touchpoint Technique. We also incorporated a range of kernel theories and service design models from the wider social sciences. We developed and tested our Trajectory Touchpoint Technique with palliative care patients and their families (n = 239) in collaboration with different hospices and hospital-based palliative care providers (n = 8).

Results

The Trajectory Touchpoint Technique is user-friendly, enables systematic data collection and analysis, and incorporates all tangible and intangible dimensions of palliative care important to the service user. These dimensions often go beyond clinical care to encompass wider aspects that are important to the people who use the service. Our collaborating organisations have already begun to make changes to their service delivery based on our results.

Conclusions

The Trajectory Touchpoint Technique overcomes several limitations of other palliative care evaluation methods, while being more comprehensive. The new technique incorporates physical, psychosocial, and spiritual aspects of palliative care, and is user-friendly for inpatients, outpatients, families, and the bereaved. The new technique has been tested with people who have a range of illnesses, in a variety of locations, among people with learning disabilities and low levels of literacy, and with children as well as adults. The Trajectory Touchpoint Technique has already uncovered many previously unrecognised opportunities for service improvement, demonstrating its ability to shape palliative care services to better meet the needs of patients and their families.

Exploring the meaning of quality of life for assisted living residents: A photo-elicitation study

Assisted living is a popular alternative to residential care, promoting independence and enabling self-care through a supportive living environment. Practitioner understanding of quality of life (QoL) experiences are vital to facilitate good physical and mental health in assisted living. An idiographic case study approach explored resident experiences by combining photo-elicitation and interpretive phenomenological analysis. QoL was understood through three themes: facilitation of identity coherence and transition, the essential nature of socialising, and perceptions of a supportive environment. Assisted living has the potential to act as a bearer for cues of identity continuity with nostalgic devices facilitating environment transition and limiting biographical disruption. Furthermore, opportunities for social contact offer a protective function for residents adapting to negative life challenges such as bereavement. To foster health and QoL in withdrawn residents' facilities should develop peer support programmes with benefits for both mentor and mentee.

The pros and cons of using photographs in nursing research

BACKGROUND

Traditional approaches to research can sometimes face difficulties in engaging participants, being flexible and ultimately eliciting data about people's experiences. Visual methods are alternative approaches that use image - often photographs - as stimuli or structure in interviews. However, little has been published in the literature to guide nurse researchers in applying and evaluating these methods.

AIM

To increase nurse researchers' awareness of visual methods and their potential.

DISCUSSION

The paper explores visual methods, with a focus on those that use photographs. It discusses the benefits of using photographs in research, such as reducing the gap between the researcher and participant and helping participants to express meaningful data. It also examines associated ethical, analytical and practical difficulties. The paper illustrates discussion points with reflections from research and compares interviews that do and do not use photographs.

CONCLUSION

Using photographs is a good alternative to more traditional approaches but the exact benefits are difficult to evidence because of the complexities of the interactions involved.

IMPLICATIONS

for practice This paper should increase nurse researchers' awareness of visual methods, help them to make informed choices about research methods and encourage the use of visual methods in health research.

Hospice Photography's Effects on Patients, Families, and Social Work Practice

This qualitative study examined the influence of hospice photography on patients' end-of-life experiences, families' experiences with hospice and grief, and hospice social work practice. Hospice photography was defined in this study as photographs of hospice patients taken by social workers in the service of legacy construction. Six social workers were interviewed about the photographs they had previously taken of patients. The themes revealed were categorized as hospice photography's perceived and potential effects on patients, families, and practice and the role of smartphone technology. The data suggested that hospice photography may positively affect patients, families, and practice due to its reported ability to build and enhance rapport, facilitate therapeutic discussion, affirm patients' dignity, worth, and self-esteem, provide opportunities for bearing witness, and increase social workers' job satisfaction. Potential effects of the use of hospice photography in social work practice included the ability to tangibly contextualize the end-of-life experience; improve termination and closure; and provide comfort during the grieving process.

Photovoice method with older persons: a review

For a long time researchers have used photography for different purposes, in different ways and with different focus. Photovoice is a qualitative visual research method that refers to photographs taken by the participants themselves. It has been used with different age groups and populations. The use of photovoice in older populations requires its own study of approaches, techniques and challenges. In this article, we review existing studies using photovoice with older participants specifically, to consider its potential as a qualitative research method in the field of gerontology. We discuss advantages and limitations of the method in gerontological research and provide guidelines for future studies. Our results show that photovoice has been used to study a wide range of topics in older people, from health issues and the impact of environment on health and wellbeing, to leisure experiences of groups living with HIV/AIDS. Using photovoice helps researchers to capture live experiences and perceptions of older persons and conduct engaging, involving and empowering research facilitating interaction, reflection and connection of participants. However, conducting photovoice studies can be practically challenging, such as when addressing special needs of the participants, or ethical and other feasibility issues. To conclude, photovoice has great potential for being used in gerontological research, it can be altered to fit specific goals, divergent issues studied and different research contexts.

Family food practices: relationships, materiality and the everyday at the end of life

This article draws on data from a research project that combined participant observation with in-depth interviews to explore family relationships and experiences of everyday life during life-threatening illness. In it I suggest that death has often been theorised in ways that make its 'mundane' practices less discernible. As a means to foreground the everyday, and to demonstrate its importance to the study of dying, this article explores the (re)negotiation of food and eating in families facing the end of life. Three themes that emerged from the study's broader focus on family life are discussed: 'food talk' and making sense of illness; food, family and identity; and food 'fights'. Together the findings illustrate the material, social and symbolic ways in which food acts relationally in the context of dying, extending conceptual work on materiality in death studies in novel directions. The article also contributes new empirical insights to a limited sociological literature on food, families and terminal illness, building on work that theorises the entanglements of materiality, food, bodies and care. The article concludes by highlighting the analytical value of everyday materialities such as food practices for future research on dying as a relational experience.

Navigating difficult conversations: the role of self-monitoring and reflection-in-action

CONTEXT

Clinicians draw upon experiential knowledge to manoeuvre difficult conversations, using tacit knowledge that is difficult to explicitly teach. Instead, learners are taught to communicate through role-play and checklists, both of which are approaches that may fail during moments of clinical complexity. We know that difficult conversations may provoke anxiety in learners, but we know little about how they learn to navigate them. Without a deeper understanding, we may fail to equip learners with the skills to manoeuvre these conversations in practice.

METHODS

Using constructivist grounded theory, we applied the sensitising concepts of self-monitoring and reflection-in-action both to explore the process in which trainees engage to navigate difficult conversations and to expand understanding about these theories. We situated our research in the neonatal intensive care unit (NICU), in which difficult conversations are ubiquitous. Fifteen resident and fellow trainees drew rich pictures about difficult conversations, and shared their drawings and experiences during semi-structured interviews. Interview transcripts were analysed using constant comparative analysis.

RESULTS

Participants described how they responded when checklist approaches became ineffective during moments of unexpected uncertainty and complexity. For participants, these indeterminate zones of practice triggered a process of seeing families differently and then pausing to understand problems that arose with the checklist-based approach. Throughout this process, learners actively observed others' communication approaches, negotiated their roles within difficult conversations, and abandoned the checklist to engage differently with families.

CONCLUSIONS

Our findings suggest links between the theories of self-monitoring and reflection-in-action, and describe the engagement of both processes in the context of NICU conversations. Self-monitoring may lead to the realisation of an indeterminate zone of practice, after which trainees may respond through reflection-in-action. We recognise that training programmes may need to teach a checklist-based approach as a starting point. We suggest that trainees also be given purposeful opportunities and support to depart from checklists in order to compassionately and flexibly navigate difficult conversations with families.