Study abroad in nursing education has grown exponentially over the past decade. The literature has a myriad of articles on the influence this type of travel has had on the personal and professional lives of nurses and nursing students as well as on the "how-to" of study abroad. A search of CINAHL for study abroad will yield more than 110 articles. The value of study abroad in nursing has been well established.
What is not discussed in any of these articles is ethical photography while on the study abroad trips. Even recent work by Steen and Zdechlik,1 who describe a semester abroad for nursing students in Uganda, do not discuss this issue. What may be found (rarely) in the nursing literature is a statement about asking for permission to take a photograph and someone's right to refuse.2
Collectively, nursing students take thousands of photographs (including selfies) while travelling to document where they have been, what they have done, who they talk to, what they eat, and as part of assignments to be completed during the trip. Most of these students are part of the millennial generation, those aged 20 to 35 years old; 81% of them are on Facebook; and 55% of them have posted a selfie.3 Thus, many of the photographs taken on study abroad trips are posted on a social media site. The photographs are also used in presentations, shown at friend and family gatherings, and often used as aides-memoires for students' journals and travel stories. Saffran4 stated, "travel is a powerful teacher, and photography is a potent story-telling tool."(p3) Part of our responsibility as nurse educators, however, is to make certain that the story-telling is in context and not reinforcing cultural stereotypes.
Humanitarian aid agencies and nongovernment organizations (NGOs) use photographs for fund raising. As discussed by Kennedy,5 "suffering sells, and guilt compels."(p7) The pain and suffering seen in photographs are central to humanitarian fundraising efforts as they bring the distant "other" into our homes. The plight of the victims leads those of us in high-income countries to feel guilty and provide funding to the humanitarian agency so that the victim is helped and suffering ends. Much of this is termed poverty porn, images that elicit a deep emotional response based on shock value and presume that those living in poverty are helpless.6 At worst, these images violate privacy and human dignity and reduce those who are marginalized by poverty to objects of pity. Seear7 adds that "people living in poverty[horizontal ellipsis]do not respond to hardship by huddling in huts, waiting desperately for the next planeload of aid workers to arrive. They do the best they can, [and] work hard under terribly difficult circumstances."(p308)
Many students have been brought up on these images and view study abroad as something more personal than just giving money from a distance. After reading approximately 30 study abroad application essays per year over the past 10 years, the main reasons that students express to go abroad are to develop cultural competency and increase global perspectives. They also want to "help" poor people in developing countries but do not elaborate on what this help entails.
Kascak and Dasgupta8 described 3 common types of photographs that are often shared on social media by students and volunteers who have gone abroad. These are also apt descriptions of the photographs that nursing students take. The suffering other shows people unable or unwilling to care for each other or themselves (true or not), which can justify paternalistic attitudes and policies.8 These may be similar to the types of photographs used by the NGOs. Nursing students will say "they should[horizontal ellipsis]" or "we should[horizontal ellipsis]" when faced with a powerful situation. For example, in 1 clinic in Bangladesh, the neonatal intensive care is a regular room with beds for the mothers who are usually holding their very ill newborns. The students are adamant that we should donate "proper isolettes" so the babies will survive without understanding that the power goes out on a regular basis, there are no generators, and there may be little follow-up care, particularly in the distant villages.
The self-directed Samaritan, the second type, are often photographs of the student/volunteer with children, appearing to have had a positive impact in the community.8 Nursing students take a great many photographs with children who have ready smiles and love holding hands, many times without asking parents' permission. There are photographs of students teaching, feeling they are making a difference. In a session of teaching first aid in a small community in Belize, one of the initial recommendations made by students was to call an ambulance. Participants said they would not do that as it was quicker to take a personal vehicle.
The last type of photograph is the overseas selfie, where the "other" is not seen "as a separate person who exists in the context of their own family or community, but rather as a prop, an extra, someone only intelligible in relation to the Western volunteer."8(p5) There are countless photographs of students with people in the community, but unless the story is about the person, it becomes another photograph of the student overseas.
How do we guard against what Woolf9 calls poverty tourism where "study abroad becomes[horizontal ellipsis]a kind of voyeurism in which privileged young Americans [or any students] go to observe relative poverty in a developing country"?(p3) How do we convince students that they are not on vacation but are there to learn about the country and about themselves? How do we ensure that the photographs that tell students' stories are in context, do not perpetuate "poverty porn" or cultural stereotypes, and are taken ethically?
We must explore the ethical principles of taking photographs as part of a comprehensive understanding of global health ethics for students before to departure. We need to begin with the purpose of the trip and the reason to take photographs. An exercise developed by Saffran4 has students choose photographs from their phones that represent positive and negative aspects of their own lives. They then caption the photograph from 2 points of view, their own and an imagined opposite character. Students begin to realize that interpreting the photograph as negative or positive depends on the viewer's assumptions.4
Knox10 interviewed Kate Otto, founder of Everyday Ambassadors, which provides resources for volunteering and study abroad,11 about digital sharing of experiences. Her golden rule was to imagine that all postings would be read/observed by everyone who is talked about or photographed. "Would they be hurt, insulted, belittled, or disempowered by your comments or photographs? Would they probably think you're misunderstanding them? Then don't post it."8(p3) These are questions that should be reviewed throughout the trip with students and can be a great discussion starter. Unite for Sight12 provides a comprehensive protocol for photography including obtaining consent, examining your motives for taking the photograph, being respectful, and not stereotyping (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A313). The protocol should not only be discussed but also be at everyone's fingertips for easy access. Above all, we need to remember the inherent dignity of all peoples as a fundamental principle of nursing.13 Discussion with students about this fundamental principle in relation to their photographs is essential.
Duane6 suggested printing images "on the spot" as a way to give back. Not being able to give copies of the photographs taken has always bothered me. When I first started taking students to Bangladesh in 2008, I found a portable photo printer that ran on a 3-hour battery to take with me. I would sit in a family courtyard and be surrounded in no time by children, mothers with new babies, and families. Even though we could not speak each other's language, it was clear how important this was for them. Mothers would clean and dress up their children (and husbands) so that they could have a family portrait, something they seldom, if ever, had. During our 6 years there, we have given away hundreds of photographs. Students need to be helped to discover the power of the photograph.
Photographs tell the stories of our lives and students will continue taking them. Teaching about ethical photography and using a protocol are ways to help students develop their understanding of global health ethics throughout their travel experience. Sharing and discussing photographs during the trip and asking about the stories students plan to tell will assist them in considering the ethics of their actions. Amerson and Livingstson's14 research provides support that a reflexive photography assignment can help to focus the types of photographs students take and increase their understanding of cultural care. Students need to realize that they will not make a big impact on a short trip; their "help" is limited, but perhaps, through their photography, they can learn something about themselves. Sometimes, as Kushner15 stated, "the first step to making the world a better place is to simply experience that place."(p4)
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