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The visual approach of photography helps to realize their process in healthcare. As you engage with patients through their photos, you'll explore diagnostic issues, treatments and therapies. Explaining the rationale for decisions will become a natural part of the therapeutic conversation.

Patients will better understand expectations of their roles and responsibilities with a stronger therapeutic relationship. Evaluating progress and processes is a collaborative effort, inspiring further engagement and mutual learning. This paper illustrates an innovative visual approach of photo elicitation to achieve fair process in clinical care for patients living with chronic health conditions, it illuminates gaps in clinical knowledge, forges better therapeutic relationships and identifies patient centered goals and possibilities for healing.

The star quality model depicts a patient's perspective of quality of life from five dimensions, technical outcomes, decision making, efficiency, amenities, and convenience in accessing care, information and emotional support and overall patient satisfaction. Increasing evidence indicates a direct link between processes, attitudes, behavior, and performance. Procedural justice leads to trust, commitment, cooperation, and exceeded expectations.

In healthcare fair process incorporates the patient's expertise into healthcare goals and strategies by engaging patients, exploring diagnostic issues, treatments and therapies, explaining the rationale for decisions, setting expectations, and evaluating progress and processes. Fair process can contribute to patient's motivation and commitment to health goals. Lack of fair process in turn can result in lowered motivation and commitment to health goals.

Two key aspects define fair process. The rational process involves diagnosing the situation, identifying objectives, considering alternatives, and discussing consequences. The relational process involves respectful communication and intellectual inclusion.

Achieving fair process may be particularly important when patients are living with chronic conditions such as diabetes, acquired brain injury or asthma. Asking these fair process questions can generate trust and align expectations. For many patients, cognitive issues, low self-esteem and fear can make it difficult to achieve fair process in clinical care.

These challenges require a creative approach to achieving fair process. Ask patients to take photographs of their situations. Then use the photographs to encourage dialogue and achieve fair process in the clinical setting.

For example, this metaphorical photo is by a man who is in a car accident and has TBI traumatic brain injury. For him, living with TBI is like trying to run on ice. The faster he runs, the more he gets nowhere.

His brain feels as slippery as ice. It cannot hold onto his thoughts. Visual methods encourage patients to explore and discuss emotions, thus complimenting clinical methods that measure their problems using statistical data.

Participatory visual methods such as photo voice allow patients to share their expertise in the clinical setting. The neuropsychologist, Dr.George Prigatano asked a brain injured patient who was angry and upset to illustrate how she felt about her herself and her injury. Creating the drawing allowed the patient to discuss her fears and forge a positive therapeutic relationship with Dr.Prigatano.

Visual methods are not appropriate to use with every patient for a study using visual methods with brain injury survivors, we used a level seven on the revised 10 point Rancho Los Amigos. Cognitive levels of functioning scale as the cutoff point for participation. Photo voice is a visual method that involves asking people to represent their lives point of view and experience using photographs and narrative.

Visual methods such as photo voice have been used for decades in community and clinical settings. First, engage the patient in the photo taking assignment. Here, the patient will be a visual researcher when taking photographs of their life and sharing them as a researcher.

The patient must adhere to ethical standards and responsibilities. Discuss possible research questions for the patient to answer with their camera. Brainstorm a couple of photo ideas.

Encourage the patient to take at least one positive and one negative photo. The patient should feel free to agree to use a visual approach or not. Since photo voice requires that patients portray experience abstractly using a photo, they may feel uncertain about what to photograph.

Show interest and sympathy for the patient experience as seen in the photo to encourage the therapeutic relationship. The patient who took this photo had a stroke. She writes, this is the front steps of where I'm living.

There are three stone steps. It makes it difficult to walk up them. Thank God there's a handrail.

Metaphors allow people to express experience and feelings that can be difficult to convey through words alone. Metaphorical photos bring emotions and life experience into the therapeutic conversation. The shell of my life became broken inside.

My head is scrambled with strands of my life no longer blended. What do you do at a stop sign? My first reaction is to stop, no wait.

My first reaction is to move forward by spinning tires on pavement. Oh crap. I seem to be stuck again since my brain injury.

This seems to be the story of my life. Encourage patients to use their camera to answer the research questions you have decided on together. For example, what in their lives helps them have better quality of life with their condition?

What slows them down? Consider the fair process questions discussed earlier. Ask the patient to bring at least one positive photo and one negative photo to their next appointment with you.

Request the patient to record notes about the photo. Why did they take it? What does it mean?

And bring the notes to their appointment. Also, Appreciate different strategies for visual expression. For example, planning the photo out carefully, taking the photo spontaneously using an image from their family album and giving the camera to someone else.

In some cases, the patient will likely have an idea first and then figure out how to portray it in an image. For example, if a messy kitchen slows them down, they may create mess just to show something that bothers them. Taking photos spontaneously does not involve planning ahead.

Some patients are comfortable taking a few snaps without thinking about them too much. It will be in looking at the photo and talking about it, that their thoughts and feelings about the image grow. Patients may prefer to bring in an image from a magazine or a family photo album.

This approach will be easier for patients who feel shy about their artistic abilities. For some, it can be a good way to start. Sometimes a patient wants to be in the picture or they may have physical or other limitations that prevent them from capturing the image they want.

Patients should feel free to give the camera to someone else to get the photo they want to show you No matter what photo taking strategies they use. Encourage patients to write down notes about their photo taking, planning, and experience Depending on your patient and their level of memory or cognitive ability. Encourage your patient to write a narrative or caption to go along with their photo.

Remind your patient to bring in their photos and written notes or captions to their next appointment. If they do not have the image with them, ask them to describe the image. Instead To begin the discussion, ask the patient what it was like to take photographs or find the image If the patient did not take any photographs or experienced challenges.

Taking photos. Discuss strategies to overcome their challenges. Practice a role play with the patient so they can gain experience explaining why they are taking photographs or asking permission.

After you have talked about the photo taking experience, ask the patient to show you an image. If they did not bring one in. Ask her or him to describe the image.

Instead, encourage the patient to teach you about the image. What does it signify to her or him? What is the image supposed to teach you?

In order to guide the photo conversations, use a series of set questions for discussing photographs. For example, these questions developed for community research purposes. Alternately return to the fair process questions or develop your own list of discussion questions.

If the patient wrote a narrative to go along with their image, encourage them to read the narrative to you. Consider the image and caption from your own perspective. Did you see in the images what the patient intended in a respectful and curious or fair process way?

Discuss what you see. Discuss possible strategies to help the patient reach their goals. Encourage the patient to write a caption to accompany the image if they have not done so already.

Patients can use a variety of strategies to write their caption. Most importantly, encourage your patients to write as if they were talking to you. Their writing does not have to be fancy or have perfect spelling or grammar.

What matters is expressing what they think or how they feel, what their hopes are and how they might get there. After you have discussed the image and what it means for the patient, ask them if they would like to try taking photos. Again, work together to determine the next photo taking assignment.

If any, repeat the photo taking and caption writing. Exercise as often as seems useful. Suggest that the patient develop a booklet or binder of images and captions.

Develop a timeline showing then and now images and captions. Alternately, use a visual approach with a group of patients. First, discuss the assignment and the ethics of being a visual researcher.

Show examples of concrete and metaphorical photos. Ask them to be prepared to share at least one image with the group at the next meeting. Group discussions provide opportunities for members to take the lead in asking questions about each other's images.

Using photos in a group can be a way for group members to learn new things about each other and deepen the sharing that occurs. Giving talks or presentations can be motivating and empowering for patients whose lives have been disrupted by a sudden illness or chronic condition. They can also be good teaching tools for other patients, family members, the general public policy makers and medical and nursing students.

Always ask permission of the before sharing their photo outside the clinical encounter or group setting. In the resources list provided, you will find links to examples of photo permission forms that have been used by photo voice projects. Now look at your list of photos that show problems and photos that show resources.

Do some images represent both a problem and a resource. Discuss this together. Next, discuss possible themes among these lists.

Consider naming the emerging categories or themes. Write the name of the theme at the top of your paper or your flip chart. The themes developed by the Brain Injury exposed project were the journey lost dreams, chaos challenges, strategies, my advocacy story, comfort and support, acceptance, hope for the future.

Categories or themes developed by other projects include courage, faith, friendship, discovery, advocacy, medical team, patient photographs, contribute to dialogue and create a bridge between the clinical setting and the patient's life world. As you discuss photos with your patient, you and your patient are constructing new meaning about their condition. Using a visual approach is one way to build the therapeutic relationship, foster dialogue, and realize fair process in your practice.

The care you provide will be more responsive, sensitive, and effective, and lead to better outcomes or quality of life for your patients. Rehabilitation and other medical professionals have long advocated for gaining an insider or patient perspective on living with disability and chronic conditions. The approach described in this visualized experiment is particularly appropriate to use with patients who have cognitive and communication issues.

Fair process means patients are deeply engaged with clinicians, so it opens an opportunity to communicate the rationale for clinical decisions. The photograph offers a powerful tool to convey the patient's experience to clearly identify roles and responsibilities of both patient and provider, to align expectations and to improve the care process.