Affective Domain Devaelopment in Virtual Education: Visual Thinking Strategies and Art Pedagogy

Document Type : Special Report


School of Nursing, Boise State University, 1910 W University Drive, Boise, ID 83725, USA


Development of the affective domain is linked to increasing self-awareness of internal dialogue, such as biases and assumptions, which can affect the ability of nurses to engage in person-centered care and meet the identified patient outcomes. Through visual thinking strategies (VTS) paired with art-based pedagogy to examine grief, loss, and bereavement concepts in a hospice and palliative care nursing virtual education course, affective domain development was advanced. Foundational to this virtual educational intervention was using the VTS framework of questions and pairing them with art-based pedagogy promoting open-ended interpretation and response to the art presented. This assisted the students in identifying relevant information, making judgments, and connecting them to previous knowledge. Using VTS with an art-based pedagogical framework enhanced person-centered competencies of empathy, understanding diverse perspectives, and advanced critical thinking and observational skills. Applying this teaching strategy to various healthcare disciplines, changing the concepts, and utilizing varying art-based pedagogical formats can easily be adapted into virtual courses, preparing healthcare practitioners to meet identified curricular needs and learning outcomes and advancing patient-centered competencies.


  1. Alastalo M. Patient observation skills in critical care nursing a theoretical construction and evaluation [dissertation]. [Turku, Finland]: University of Turku; 2021 [cited 2023 Jan 11]. Available from:
  2. Collier NB, Taylor L. Fostering awareness of implicit bias using an adapted visual thinking strategy and reflection. J Physician Assist Educ [Internet]. 2022 Jun;33(2):145-7. doi:10.1097/JPA.0000000000000425.
  3. Poirier TI, Newman K, Ronald K. An exploratory study using visual thinking strategies to improve undergraduate students’ observational skills. American Journal of Pharmaceutical Education [Internet]. 2020 Apr;84(4): 451-8. doi:10.5688/ajpe7600.
  4. Driscoll MP. Psychology of learning for instruction. 2nd Boston (USA): Allyn and Bacon; 2000.
  5. Lease L. Teaching, learning, & everything in between Krathwohl and Bloom’s affective taxonomy [Internet]. 2018 Aug [updated 2018; cited 2023 Jan 13]. Available from:
  6. Simm D, Marvell A. Gaining a “sense of place”: students’ affective experiences of place leading to transformative learning on international fieldwork. Journal of Geography in Higher Education [Internet]. 2021 Nov;39(4):595-616. doi:10.1080/03098265.2015.1084608.
  7. Papathanasiou IV, Kleisiaris CF, Fradelos EC, Kakou K, Kourkaouta L. Critical thinking: the development of an essential skill for nursing students. Acta Inform Med [Internet]. 2014 Aug; 22(4):283-6. doi:10.5455/aim.2014.22.283-286.
  8. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMS Med Ethics [Internet]. 2017 March;18(1):1-18. doi:10.1186/s12910-017-0179-8.
  9. Reiger KL, Chernomas WM, McMillan DE, Morin FL. Navigating creativity within arts-based pedagogy: implications of a constructivist grounded theory study. Nurse Education Today [Internet]. 2020 Aug;91:1-9. doi:10.1016/j.nedt.2020.104465.
  10. Obara S, Perry B, Janzen KJ, Edwards M. Using arts-based pedagogy to enrich nursing education. Teaching & Learning in Nursing [Internet]. 2022 Jan ;17(1):113–20. doi:10.1016/j.teln.2021.09.003.
  11. Aspden T, Egan JP, Bye L, Petersen L. Using visual thinking strategies to support development of pharmacy student competency in person-centered care. American Journal of Pharmaceutical Education [Internet]. 2022 Mar;86(3):217–25. doi:10.5688/ajpe8607.
  12. Yenawine P. Visual thinking strategies: using art to deepen learning across school disciplines. Cambridge, MA: Harvard Education Press; 2013.
  13. Kelly-Hedrick M, Chugh N, Zahra FS, Stephens M, Chisolm MS. Art museum-based teaching: visual thinking strategies. Academic Medicine: Journal of the Association of American Medical Colleges [Internet]. 2022 Aug;97(8):1249. doi:10.1097/ACM.0000000000004600.
  14. Sikkema S, Lee J, Spilberg J, Dahn M, Yankova N, Peppler K. How the arts can unlock a closed curriculum. Phi Delta Kappan [Internet]. 2021 May;102(8):20–5. doi:10.1177/003172172110139.
  15. Cavanagh SR. The spark of learning: energizing the college classroom with the science of emotion. Morgantown, WV: West Virginia University Press; 2016.
  16. Bertman S. Hannelore Wass: insights into creative teaching and other ways of knowing when facing aging and mortality. Death Studies [Internet]. 2015 Oct;39(9):537–44. doi:10.1080/07481187.2015.1079451.
  17. Stensæth K, Eide IB. Umberto Eco’s notions of the “open work” and the “field of possibilities”: New perspectives on music therapy and co-creation? British journal of music therapy [Internet]. 2017 Nov;31(2):86–96. doi:10.1177/135945751667862.
  18. Rudebeck CE. Relationship based care – how general practice developed and why it is undermined within contemporary healthcare systems. Scandinavian Journal of Primary Health Care [Internet]. 2019 Sep;37(3):335–44. doi:10.1080/02813432.2019.1639909.