The arts and humanities have long been recognized as important tools for building clinical reasoning and cultural sensitivity in nursing education.1 Although much of students' liberal arts education takes place in general education courses, there is growing evidence to suggest that integrating the arts into nursing courses can have powerful outcomes. For instance, reading poetry can influence nursing students' sense of discernment and ethical regard for others.2 Engaging in art therapy can be used to teach reflection and professional values.3 Most notably, art can be used to teach observational skills and attention to detail.4 This article explains how an art-based teaching technique, Visual Thinking Strategies (VTS), can be used in nursing education.

Visual Thinking Strategies

Visual Thinking Strategies invites participants to discuss works of art in an art museum with a trained facilitator. This teaching technique was originally created as a way to engage museum visitors with artwork for a more prolonged period of time.5 According to Vygotsky's educational philosophies, students are more likely to synthesize learning when engaging and socializing together.6 Visual Thinking Strategies has been used extensively in primary education.5,7,85,7,85,7,8 More recently, VTS been studied in medical and nursing education as a way to improve observational and communication skills.9-119-119-11

To initiate this process, typically, 3 works of art are chosen by the VTS facilitator, which is standard to the VTS process.7 The trained VTS facilitator spends approximately 15 to 20 minutes engaged in conversation with participants for each work of art. As students gather around a work of art, the facilitator asks them a series of 3 questions:

1. What is going on in this picture? This question invites the participants to think aloud about what they are seeing, using a narrative to describe what they think, see, or interpret as meaning in the painting.

2. What do you see that makes you say that? This question requires the participants to give visual evidence for what they are seeing and back it up with details. This statement also requires them to look again at the painting and find factual evidence that contributes to the understanding of what was meant. Facilitators give no indication that they are judging or that the response was right or wrong but instead listen intently and often point to areas of the piece as the participants describe it. This keeps all participants focused on the painting. The facilitator remains present and paraphrases back to the participant what was said, using phrases to clarify understanding such as: "Did I understand you correctly?" and "Is that right?" The participant may agree or may look again and clarify the meaning. Through this interaction, participants often report feeling validated and gain an understanding of phrases that make them feel acknowledged.

3. What more can you find? This question invites others to participate. After watching the initial interaction between the first participant and the facilitator, others notice that there was no judgment or correcting, and the answers were respected and validated. This encourages other participants to offer their interpretations of the painting. After a participant responds, the facilitator listens and then paraphrases back with "What are you seeing that makes you say that?" Often, participants will build on each other's comments and may have various interpretations about the painting.

At the end of the discussion, the facilitator thanks the participants for their observations and the group moves on to another work of art. The same 3 questions are asked by the facilitator with each work of art. Discussions typically last about 20 minutes per art piece, making the length of the entire activity approximately 1 hour.

Classroom Integration

Traditionally, VTS is done in an art museum by a trained facilitator. Information can be obtained about participating museums and programs at http://www.vtshome.org. Students from a variety of health care settings can meet at the art museum for VTS experiences during hours that are most convenient. Because participants learn to listen attentively and respectfully to each other, and all learners' opinions are valued, VTS is a venue for interprofessional learning.9

The VTS can be modified for use in the classroom with the teacher projecting selected works of art on a screen. The teachers should allow students to answer each of the 3 questions before going to another participant for sharing. Groups of 10 students or fewer are encouraged to allow adequate time for all to participate and for a rich discussion to occur.

We offer VTS as a homework option in our obstetrics course, and frequently, medical students are invited to participate. Our group meets at the local art museum, and we have a trained VTS facilitator lead the group through 3 works of art. At the end of our VTS discussions, we talk about how we might use VTS in caring for obstetrics patients. Students discuss a variety of ways that this technique could be used, including obtaining on obstetric history on a new patient. Others have identified that the process of VTS may be helpful in gaining insight into patient pain after a C-section. It also may help students give a more thorough report about labor patients, listening to patients such as the facilitator did with them during VTS and backing up their observations with visual evidence.

Visual Thinking Strategy discussion facilitation skills may be transferable to other classroom and small group situations. As nurse educators demonstrate an understanding of each student's response, they model mutual respect, which in turn facilitates further communication. By practicing this technique, they learn how to invite maximum student participation and expansion of thought. In addition, VTS can also help teachers learn to shape responses to everyday discussions in ways that are respectful and thoughtful. Furthermore, when teachers learn to listen carefully to a student in other discussion forums, they can identity any misconceptions needing clarification or correction.7

Conclusions

Visual Thinking Strategies offers nurse educators an opportunity to use art for conversations that involve listening intently, considering others' opinions, and giving details to communicate ideas and observations. Whether going to an art museum and using a trained VTS facilitator or using artwork in the classroom, VTS holds potential for nurse educators as strategy to enhance communication and observational skills and for interprofessional learning. The role of the facilitator sheds light on teaching opportunities for nurse educators to demonstrate facilitative teaching in the classroom, validating student responses and showing mutual respect.

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