There is a burgeoning of non-arts disciplines, such as nursing and medicine, integrating arts media into pedagogy.1-4 These media include visual images, poetry, sculpture, dance, music, painting, and drama, among others.2,4-6 Although this teaching-learning approach has many labels, for example, arts-based pedagogy and arts-based learning, we find the term arts-enriched pedagogy is most suiting to our needs as nurse educators because it highlights how the arts richen and cultivate learning experiences. The arts are not the focus or threshold to demonstrate that learning has occurred, but rather used as a means to learn about another topic.7

In nursing and medicine, arts-enriched pedagogies have been shown to develop students' self-awareness, prompt critical inquiry and dialogue, and enhance capacity for reflective practice, communication, and empathy.1,4,5,8 While exploring clinical reasoning among medical students, authors have noted that observation skills can be honed by using arts-enriched pedagogies that incorporate dance and paintings.9,10 Art as a teaching strategy opens up discussion rather than restricts potential outcomes.11 Artistic forms of teaching provide an opportunity to show and not just tell,11 affording a type of experiential learning as opposed to didactic approaches.

Arts-enriched pedagogy is inherently compatible with clinical reasoning as the teaching strategy itself exemplifies fluid and flexible thinking, adaptive to the classroom context. As students share their reactions to art, it is the educator's role to navigate the conversation and guide the (re)evaluation of initial insights. Similarly, clinical reasoning requires exercise of flexibility, in which students learn to assess and examine patient data analytically and make refinements to clinical judgments as they consider alternative explanations.12 According to Levine and Bleakley,13 errors most often occur early in the clinical reasoning process; therefore, flexibility is an important skill to develop as it allows learners to revisit and evaluate their initial insights.

Our Pedagogical Purpose

We used visual images to move prelicensure nursing students through processes that resemble clinical reasoning and prompt them to critically reflect. Although these visual images are from a social gathering, the activity simulates the experience of clinical reasoning related to the process of discovery and data collection. We drew upon Kolb's14,15 Experiential Learning Theory that assumes that learning is an active and reflective process. McIntosh16 suggests that arts pedagogies are experiential by nature because students are actively exploring during the learning process. The idea of actively exploring fits well with clinical reasoning in which students are expected to examine patient data and recognize cues to determine what is going on.

The Learning Activity

This visual arts activity occurred within a large class and took about 15 minutes to complete. It was performed in the context of a year long health assessment course. The course had lecture and laboratory components in which students learned about and practiced skills related to communication and physical, psychosocial, cultural, and spiritual assessment. The course was situated in year 1 of a 4-year baccalaureate nursing program across 3 geographical sites. The activity was delivered by several educators in multiple course sections. Class sizes typically included 25 to 55 students per section. To date, this approach has been used with more than 700 first-year nursing students.

Prior to class, students were required to complete readings about the clinical and diagnostic reasoning processes, specifically attending to cues and gathering patient data and formulating and evaluating hypotheses.17 After discussing clinical reasoning in class, a series of 5 photographic images (embedded in a PowerPoint presentation) were individually projected on a large screen to the whole class. No introduction of the activity was provided to the students (see Photographs 1-5, Supplemental Digital Content 1, http://links.lww.com/NE/A244).

Each image was displayed for about 3 minutes. The first image showed part of a person's face, and then with each subsequent image, more detail was provided until the final image of the complete picture. A similar series of images could be used to replicate this activity in other health assessment courses.

With each image, students reflected individually and then shared their perspectives through group discussion with the class as a whole. With the first image, we asked students to discuss the following questions: "Who is this person? Where is the person? What is the person's emotions? What is going on?" We asked 1 question at a time and asked the next question when the discussion began to taper. As students continued to brainstorm, we probed further: "What makes you think this?" We encouraged students to look closely at the image and examine all parts of it. After in-depth discussion, the next image was exhibited. We continued to ask those questions and additionally asked: "Has your assessment changed and why?" As well, we asked students "What is important to pay attention to in the images and why?"

Similar to clinical reasoning,12,17 these questions prompted students to iteratively examine the images for cues and generate multiple hypotheses about what was going on. It was important to ask "what makes you think this?" throughout the process, as this question prompted students to make reasoned judgments by analyzing data and explaining their hypotheses, all of which are important to clinical reasoning. In addition, this question furthered the clinical reasoning process as students were challenged to ground their answers in the data provided, in this case the visual image. The group dialogue introduced students to multiple perspectives, and as a result, they were prompted to challenge their abruptly formulated assumptions and explore ways in which their thinking changed as more information became available. We found that the dialogical encounters that emerged from use of visual images influenced students to reevaluate their thinking based on newly acquired information and other students' ideas. For example, students would often respond to other hypotheses by saying, "I never thought of that, but now I can see that in the picture" or "The facial expression of the person in the image's background is inconsistent with a traumatic event." Our learning activity echoes existing literature indicating that dialogue is vital to sound clinical reasoning.13

Asking students "why" prompted them to discuss their uncensored initial thoughts in response to visual images. For example, students initially hypothesized about whether the person in the image was a patient and questioned whether the person recently received a diagnosis. These were common first comments considering that the activity occurred in the context of a health assessment course. As the activity progressed, students engaged in dialogue with each other and critically reflected on their own assumptions, made inferences that were grounded in the data, clustered related cues by examining the whole picture, and distinguished relevant from irrelevant data within each of the images.

We plan to integrate other questions into future iterations of this activity such as "When looking at this picture, what do you see? Feel? Hear? Smell?" These questions may challenge students to expand their thinking in more aesthetic ways. It also may be worthwhile to encourage students to individually document reflections to the questions and series of images and then share these in a think-pair-share activity; this may provide the opportunity for quieter students to be more actively involved. However, it is noteworthy that the majority of students engaged in the discussions. This participatory level may suggest that arts-enriched learning activities may reduce students' apprehension, promoting engagement and active involvement in large class discussions. An additional step would be to facilitate conversations in which we deconstruct potential clinical implications resulting from premature assumptions and preconceived ideas; this would allow students to see how expanding dialogue in the clinical reasoning process is vital.

Conclusion

Arts-enriched teaching with the use of visual images requires students to recognize clinical reasoning as an iterative rather than a linear process. As a teaching-learning tool, visual images can be used to challenge students' habits of the mind and prompt them to critically examine the underlying thinking associated with their clinical reasoning.

References