The SEED Team journey: A phenomenological study of a multidisciplinary healthcare team's experience using the new creative tool photovoice for critical reflection

Christopher Robert Marjoribanks¹, Leanne Cummins¹, Padmini Pai¹

Abstract

Purpose

This paper describes how a newly formed multidisciplinary healthcare team used photovoice as a creative way to improve team bonding and explore individual and team wellbeing.

A phenomenological methodology was used to explore connections and team bonds in the Stability Encompassing Endurance Direction (SEED) Team, a newly formed team of healthcare professionals, using photovoice.

Findings

The SEED Team's reflections provide insights into using creative photography as a way to express feelings and the importance of wellbeing. The process encouraged individuals to take time away from their cognitive task state.

Research implications

The use of photovoice in a newly formed team highlighted the effectiveness of reflective practice that can strengthen team connections and provide opportunities to take a break.

Originality

This study explored a simple yet powerful tool from an experiential perspective. The tool has potential for use in future wellbeing activities and initiatives. The process added value to the participants' existing facilitation skills and fostered awareness of their surroundings while taking creative photographs.

Keywords: photovoice, SEED, reflection, connections, wellbeing

Introduction and background

The Stability Encompassing Endurance Direction (SEED) Program is an innovative workplace wellness model that commenced in 2019 in the Illawarra Shoalhaven Local Health District (ISLHD), a regional area in New South Wales (NSW), Australia (Pai et al. 2022). The SEED model uses co-design and implementation science to enable consumers (healthcare staff) to become equal partners in the improvement process (Agency for Clinical Innovation 2022). Implementation science ensured the SEED model could adapt to real-world circumstances and that the research could be applied to local settings, as all healthcare areas are unique and have different barriers (NSW Health 2021a).

The SEED Program was born out of the 2019 bushfires in the southern part of the district (Milton Ulladulla) and further cumulative natural disasters, including the COVID-19 pandemic. The ISLHD initiated a strong focus on staff wellbeing, resilience and recovery, coinciding with the publication of the Elevating the Human Experience guide to action by the NSW Ministry of Health (NSW Health) (NSW Health 2021b; Pai et al. 2022). The SEED Program's success in 2019 led to further interest and investment from the ISLHD Chief Executive (CE) and the NSW Health Chief Experience Officer to support the development of a new SEED Team. A narrative inquiry into the practices of healthcare workers who had experienced the SEED Program identified eight wellness practices that supported healthcare workers (Olcon et al. 2022):

1. responsive and compassionate leading
2. co-designing wellness activities with staff
3. listening to understand
4. creating a safe and healing space
5. connecting with others
6. collective caring
7. diversifying and localising wellness activities
8. striving for sustainability.

A multidisciplinary team was formed to accelerate the uptake of SEED over eight weeks. Recruitment was finalised in May 2022. The SEED Team was structured in the ISLHD Clinical Governance Unit. Its safety and quality improvement expertise helped with role modelling and staff wellbeing. The SEED Team comprised staff from various disciplines and sites around the district, including a clinical nurse educator, a social worker, an executive assistant, an occupational therapist, a divisional support officer and a clinical midwifery specialist. They began their journey with a unique two-day orientation using SEED elements to strengthen team connections.

The SEED Team was given a project management plan that outlined weekly objectives and goals for the eight weeks. Phenomenological methodology and photovoice reflection methods provided insight into the team's thoughts and feelings (Budig et al. 2018). Phenomenology is the qualitative study of lived experience, particularly reflecting on and writing about an experience (Errasti-Ibarrondo et al. 2018).

Photovoice is a participatory creative method that uses a photograph to create a reflection (Budig et al. 2018). Consent forms to share media were signed by each team member. This study complied with Human Research Ethics Committees--Quality Improvement & Ethical Review: A Practice Guide for NSW (NSW Health 2007c) and was approved by the ISLHD Ethics Committee.

Photovoice can enhance community dialogue, facilitate reflection, encourage engagement and elicit authentic data through sharing lived experiences (Liebenberg 2018). The team was introduced to the stream of consciousness narrative communication style, a form of cognitive neuroscience that allows the mind to wander so an individual can document their experience, feelings or behaviours (Smallwood & Schooler 2014). Stream of consciousness allowed the team, using photovoice, to capture their thoughts, perceptions and mental content through the neurocognitive process of taking a photograph and describing it (Smallwood & Schooler 2014). This process is described as a drift from the 'current train of thought (often an external task) to mental content generated by the individual' (Smallwood & Schooler 2014, p. 6), also described as mind-wandering. People can spend 25 to 50 per cent of their waking hours engaged in thoughts unrelated to their present moment, leading to a positive or negative mood, including depression and anxiety (Smallwood & Schooler 2014). Mind-wandering that focuses on the past can lead to unhappiness, however 'an interesting mind-wandering' (Smallwood & Schooler 2014, p.14) experience can lead to a positive mood, as demonstrated in the participants' photovoice pictures and descriptions (Smallwood & Schooler 2014).

The overall aims and objectives of this paper are to explore:

1. the introduction of photovoice as a new creative tool to a newly formed team of multidisciplinary healthcare workers over eight weeks
2. the influence of photovoice on individual wellbeing and team building.

Method

Recruitment for SEED Team positions, including one project co-ordinator and six facilitators, was through the internal NSW Health Recruitment Onboarding System (ROB). The successful candidates met on the first orientation day, 2 May 2022. During the two-day orientation, participants consented to the project by signing the ISLHD media image consent form, approved by the ISLHD Low and Negligible Risk (LNR) committee. The project was considered a practice/quality improvement project not requiring any further ethical review. Each participant was given an information sheet on stream of consciousness and the consent forms. The ethics application 'Photovoice: a reflective practice to improve bonding in a new team' was approved (ISLHD/QA154).

In this study, photovoice involved participant-generated textual and photographic data captured using mobile phone technology. Seven team members began using photovoice during orientation to their new role and continued to use photovoice for six weeks. A mobile WhatsApp group was created, and each team member was asked to take a digital photograph once per week, followed by a text reflection on the photograph and why they took it. A total of 44 photographs with 44 corresponding texts were captured over the six weeks, which were analysed and themed. Seven photographs are included in this article for visual representation.

The photographs and reflections were uploaded to the WhatsApp group for participants to share their experiences.

FINDINGS

Spontaneous or directly induced mind-wandering can be measured using Magnetic Resonance Imaging (MRI) (Smallwood & Schooler 2014). However, Smallwood and Schooler (2014) discuss the challenge posed by evoking mind-wandering for assessment, including directly causing an individual's mind to wander. Spontaneous mind-wandering occurrences that link experiences to processes are not transparent. This study demonstrated that a researcher can have some control over directly inducing mind-wandering with stream of consciousness. Initiating and implementing photovoice to describe an experience with an image to the team resulted in participants ceasing what they were presently doing and taking time to take the photograph with a description. Group participation was enhanced when team members reviewed each other's WhatsApp messages and photographs and replied with their photographs shortly after.

A mixed method approach was utilised to analyse the data, involving researcher thematic analysis and content analysis performed with the Leximancer software program (Ward et al. 2014). The researcher employed thematic analysis as the first method, where they familiarized themselves with the data, created and organized codes, and identified and labelled themes. The second method involved entering participants' quotations into Leximancer over six weeks, which used algorithms and word associations to identify concepts and generate themes. Language is a window into the mind and the words people use can provide insight into knowledge and thoughts (Wolff et al. 2010). When we speak or write, we use concepts in our language and the concepts in a group of people who have shared needs, goals and feelings, could be more tightly linked if their thoughts are grounded in universal concepts (Wolff et al. 2010). By converting natural language into a semantic language, Leximancer learned the primary concepts and how the texts were related to one another (Ward et al. 2014). Semantics, which is concerned with the relationships among words, sentences, and meaning, is a branch of linguistics (Vocabulary.com 2022). Leximancer produced "thesaurus iterations" like SEED, team, world, different, and connections based on the data, indicating that the SEED project was aligned with the goals of the Elevating the Human eXperience guide (NSW Health 2021b), which prioritises connection and togetherness as the foundation of individual and collective wellbeing. The human experience and interactions between staff and patients are shaped by culture, values and different beliefs that can influence patient perceptions across the continuum of care (NSW Health 2021b). The photovoice reflections revealed that the SEED Program allowed participants to establish strong connections with each other, resulting in the flourishing of individual and team wellbeing.

Leximancer generated a transparent model that captured themes. The three most common themes chosen to analyse were SEED, reflection and 'take'. These themes were then interpreted by reviewing the concepts associated with each theme (Leximancer, n.d.). This is represented in a conceptual map (Figure 1).

Figure 1. Conceptual map

Leximancer conceptual maps cluster concepts (smaller grey circles in figure 1) into higher-level themes, represented by coloured circles that are heat mapped or colour coded from hot to cold to signify the prevalence of the theme (Leximancer 2021). The most significant theme appears hot (red), and the less important themes appear in cool colours (blue, green), according to the colour wheel (Leximancer 2021). In Leximancer, the size of the circle is not a reflection of the frequency of the words in the text, but rather the connections between words travelling across boundaries of the circle. The size of the circle does not represent the prevalence of the texts. The connections between words travel through the circle boundaries.

Some of the themes Leximancer drew from connections between words travelling together through the text were similar to themes found by the researcher using thematic analysis. Two new themes emerged through Leximancer.

The themes of connections, strong bonds, teamwork, reflection and nature were identified by the researcher through analysis of photographs and descriptive text. The distinction between thematic analysis conducted by the researcher and the use of Leximancer software lies in the fact that the researcher possesses knowledge of the context and meaning of the images, while Leximancer does not have any pre-existing understanding of the subject matter. However, SEED and 'take' were not identified as main themes throughout the text by thematic analysis, even though the word SEED appeared 15 times, as specified in Leximancer. 'Take' was overlooked as it did not stand out compared to words like focus, rainbow or light. 'Take' as a theme was considered the most significant finding, as it was not considered that staff needed to take wellbeing from a mindset point of view. Some individuals may not allow themselves to take a break or may not know how, even if they have the opportunity and support to do so.

The outcomes were a strong connection to nature and the SEED Program, deep reflection and taking time to prioritise individual wellness. This led to a transformation of team members' perspectives on the importance of their wellbeing, the wellbeing of healthcare staff and using creative photography to express their feelings. Key learning outcomes were using photovoice as a new medium and stream of consciousness to enable authentic reflection and deep, meaningful, creative collaboration among team members. This built trust and allowed team members to connect deeply and care for each other's vulnerabilities. Participants offered different perspectives and thought processes through the photograph descriptions. For example, the photograph in Figure 2 could suggest putting your car in low gear and staying within the speed limit, but one participant linked it to pausing after completing tasks.

Figure 2.

Remembering to pause after ticking lots off the list!

THEMES

SEED

SEED or the SEED Program was referenced 15 times out of the 44 photographs in a variety of ways, for example, being hopeful for the SEED Program, the dawn of new beginnings, a 'messy' space before 'it gets going', caring for the world to make it a better place, trusting each other through SEED, energising self and enabling the thought to stop, taking time to think and enjoy nature.

Participants involved in the SEED Program since its beginning identified eight SEED practices. These practices strongly focus on responsive and compassionate leadership, which has been a success of the SEED model (Olcon et al. 2022).

Table 1. SEED practices

Number	Practice	Description
1	Responsive and compassionate leading	Immediate recognition and response can have positive impacts to individuals and staff
2	Co-designing wellness activities with staff	Co-design creates a sense of ownership, inclusion and collaboration
3	Listening to understand	Benefits those listening and being heard
4	Creating a safe and healing space	A safe space creates psychological safety and provides the opportunity to share stories
5	Connecting with others	Deep connection can lead to staff having more compassion, caring and understanding of each other
6	Collective caring	Caring for each other creates a sense of connection between colleagues and increases kindness between others
7	Diversifying and localising wellness activity	Caring for each other creates a sense of connection between colleagues and increases kindness between others
8	Striving for sustainability	Flexibility and adaptability is important to suit individual site needs

The SEED Team met with the ISLHD CE, who asked each team member to discuss their work. One team member introduced the CE to photovoice and gave the example of their photovoice from that morning, a picture of a rainbow (Figure 3). The CE replied with a gentle smile that they had seen the rainbow too, and they commented on how nice it looked. This is a strong example of SEED Practice 5 and leaders sitting as equals. 'Who would have thought we would be having conversations with the CE about rainbows?' (SEED Facilitator, personal communication, 12th May 2022). SEED Practice 5 is 'connecting with others'. Having deep authentic connection with others can lead to conversations with colleagues that are not always work related (Olcon et al. 2022).

Figure 3.

SEED made me stop and take in this rainbow over Keiraville this morning.

Figure 4 shows an example of SEED Practice 2, 'Co-designing Wellness activities with staff'. The fully participatory, inclusive and collaborative process of co-designing wellness-orientated activities result in staff feeling a sense of ownership, as utilising each other's strengths can empower individuals (Olcon et al. 2022).

Figure 4.

This calendar picture for the month of May is titled 'the world that nobody owns'. [It] reminds me of SEED [because it] is 'messy before it gets going'. Our team all playing our part and embracing our different strengths and focus … I like the title because for me the world doesn't belong to us-we are its caretakers for the time being and hope/want to leave it a better place than we found it … this mirrors what SEED can mean in the context of health organisations.

REFLECTION

Self-reflection was seen to break down barriers between participants and enhance team bonding (Figure 5). Reflection is linked to SEED Practice 6, 'collective caring'. A sense of responsibility for the wellbeing of others produces a work culture where colleagues strive to help each other to be well (Olcon et al. 2022). Creating a safe space and a sense of connection among staff showed they were more likely to be kind, respect each other, care for each other authentically and put people before processes.

Figure 5.

Breaking down barriers with self-reflection and the hopefulness of SEED.

During orientation, participants made a visual representation of the connections they made with each other over two days (Figure 6). The links ensured that all team members got to know each other. One participant discussed having important conversations in a peculiar space (the parking lot next to rubbish bins, demonstrating humour) and how this strengthened team bonds (Figure 7).

Figure 6.

Connections made in three days. Bonded to become a team.

Figure 7.

The car park I have not parked in, I love the walk up from the road. I find it very curious that the car park would take centre stage overlooking the beautiful ocean with the hospital behind looking at the carpark. Yet, two important conversations took place in the car park space, both on day one-the first, a reflection on why the car park and the bins are here (humour) and the second was a bond [that] was strengthened at the end of the day. And as an add-on, a third lovely moment happened in the car park at the end of today-another bond strengthened.

The staff worked well together in this short project. The SEED Team was connected and bonds were strengthened through the process.

TAKE (TAKING TIME)

SEED encouraged participants to take a break, take a breath and stop and not to 'sweat the small stuff'. 'Take' was referenced in the context of mother nature taking away life's problems in a picture of the sand, ocean and sun gazing high above (Figure 8).

Figure 8.

Mother Nature can take all troubles away.

The quotation with figure 9 advised taking time to stop and focus.

Figure 9.

In the world of wellbeing we always give from our 'brim', not from our 'empty'. To do this well we take time to stop and focus on messages within the cup.

'Take' links to SEED Practice 4, 'creating a safe and healing space'. This practice discusses intentionally providing the opportunity to create a safe space. Using self reflection in this space allows staff to focus on wellness and healing in the workplace (Olcon et al. 2022) There is an increasing need for staff to take a break and take care of themselves to enhance their wellbeing and patient outcomes.

Figure 10.

I'm walking the talk, taking time out for me.

The SEED Team saw 'take' as an emerging phenomenon as SEED is a wellbeing model focused on giving and allowing leaders and staff to participate in wellbeing activities during work. Facilitated by SEED workshops and education, the SEED Team felt they needed to practice what they preached and take opportunities for their own wellbeing. One participant captioned a photograph 'Stop, think, take a breath, and don't sweat the small stuff'.

The photovoice images prompted reflections on the significance of both team and personal wellbeing, emphasizing the importance of seizing opportunities to priorities self-care. The use of photovoice also fostered better communication within the team, encouraging informal discussions with high-ranking executives on topic such as rainbows. Educating and facilitating staff wellbeing is essential. Rather than solely being about individuals receiving wellbeing, it can also be seen as the SEED Team empowering staff to take responsibility for their own wellbeing, ultimately promoting greater sustainability.

STRENGTHS, LIMITATIONS AND IMPLICATIONS FOR PRACTICE

While the number of participants in this study was small, a strength of this study was the introduction of photovoice as a new creative medium for reflection within a multidisciplinary team. Further research is required to establish its contribution to bonding within teams. Photographs uploaded by staff were an effective and creative way to improve team bonding and explore wellbeing.

Discussion

This paper has discussed the use of photovoice to describe the SEED Team's individual and shared experience. Photovoice provided insights into using creative photography to express feelings and the importance of wellbeing. It encouraged participants to take time away from their cognitive task state and created an opportunity for them to change to less intense activity, allowing the mind to wander. High attention demanding tasks, such as mathematics, can increase mental and physical fatigue (Shan Huang et al. 2020).

Hannay et al, (2013) reported on a group of nineteen teenagers and six adults who utilised photovoice to lend weight and authenticity to their personal accounts of the challenges and circumstances in their neighbourhood. Barriers to physical activity outside of school hours, such as busy family schedules, racism, inadequate transportation, and crime, including gang violence and drug use, were among the topics explored. Through reflective writing, participants were able to capture an image and narrate their thoughts and emotions in their own words, providing a meaningful voice in the decision-making process. The teenagers showcased their photovoice narratives to a state-wide audience at Connecticut's 2nd Annual Physical Activity and Nutrition Symposium, effectively representing their community. The reflective writing process bolstered the credibility of each story and contributed to several positive initiatives, including a free 60 hour fitness program for teenagers that combined career development and leadership skills, as well as a signed petition, endorsed by 100 people, urging the Common Council to reopen a community pool, with support from the current mayor (Hannay et al., 2013). By utilising critical reflection, the participants were able to document their strengths and priorities, and to contemplate what factors might effect social or professional change (Bowers, 2017).

Photovoice has also been used for health and safety. A scoping review and literature research produced an overview of current photovoice designs and applications in the health and safety domain and found that photovoice has strong potential to support safety management (Lindhout, Teunissen & Reniers 2021). Safety management faces increasing challenges from human factors, such as safety culture and worker behavior, as well as from complex installations and environmental constraints. To better understand these interactions, safety management could benefit from using methods that provide insight into what is happening between people, equipment, and their workplaces (Lindhout, Teunissen & Reniers 2021). Lindhout, Teunissen and Reniers (2021) found that photovoice can offer a different mode of expression for people to share their experiences in safety management and that the human element is also critical in occupational health and safety, clinical incident management and education. Photovoice is a powerful tool that can be used by workers themselves in specific settings or represented by a union to communicate with safety regulatory agencies (Lindhout, Teunissen & Reniers 2021).

The literature demonstrates how photovoice can be used in various ways to enhance engagement, communication and empowerment. These elements common to our study highlight how photovoice can be used in different settings as it creates room for a voice in a safe and creative space.

Although SEED is modelled on a strength-based growth model approach, using photovoice during SEED activities, projects and workshops could empower staff to be courageous and take ownership of their wellbeing. The SEED Team was fully engaged in using photovoice to reflect, bond and explore wellbeing individually and as a team.

Conclusion

Photovoice is a safe, simple and fun medium to quickly embed meaningful connections, strengthening participant bonds. Using photovoice within a multidisciplinary team is an effective and creative way for staff to reflect, enhance bonding and explore individual and team wellbeing.

Acknowledgements

We would like to acknowledge and thank the SEED Team for their contribution and collaboration in using photovoice to strengthen the team. We would also like to acknowledge the CE and the Clinical Governance Unit Director of ISLHD for their leadership and support within the SEED Team.

Conflict of interest

The authors have no conflict of interest to report.

Funding

The authors did not receive any funding to use photovoice.

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