Both the original and the revised forms of Bloom's taxonomy have been significant contributors to curriculum development in many disciplines including nursing (Bloom, 1956; Krathwohl, 2002; Krathwohl et al., 1964). The taxonomy, which evolved over several years and with several different contributors, generally refers to three domains of learning: psychomotor, cognitive, and affective. With the psychomotor and cognitive domains representing skills and knowledge, the affective domain describes the components of learning that consider feelings, emotions, and attitudes. Although skills and knowledge are prominent in the RN standards and curricula for practice in the United States, the United Kingdom, Australia, and New Zealand, as well as many other countries, the components of the affective domain are less obvious. A lack of clear affective learning outcomes in such standards reflects the challenge of defining and measuring student achievement in this domain.
To enable inclusion of the affective domain, it is important to consider how the components of the affective domain are fundamental to the “next wave” of pedagogy in health professional education (Stephens & Ormandy, 2018). New technologies, such as 360° videos viewed within a virtual reality (VR) headset, provide innovative, immersive, and satisfying teaching methods. This article describes how the affective domain was integrated into the conceptualization and production of a 360° video.
Affective Domain in Nursing Curricula
Despite the lament of Pierre and Oughton (2007, p. 1) that the Affective Domain is the “…undiscovered country,” it is acknowledged that there is indeed a level of affective learning implied in many nursing curricula. Several authors (Gallo, 2003; Hanson, 2011; Myers & Goodboy, 2015; ten Cate & De Haes, 2009) argue, however, that an implied level of affective outcome is inadequate and call for greater integration and transparency of affective learning in a range of health curricula and forms of assessment. Donlan (2018), Johns and Moyer (2018), and Valiga (2014) also make important arguments for inclusion of affective taxonomies in health education. Valiga (2014) sagely argues for a “better balance” between the domains and the development of nursing students.
The concern remains that implied or tacit references to the taxonomy will not elevate its consideration in learning and teaching to the level of emphasis shared by “skills” and “knowledge.” An example of this reduced visibility is the Australian Qualifications Framework (AQF; https://www.aqf.edu.au/), which carefully describes 10 unique levels of educational development for skills and knowledge but makes no explicit reference to the affective domain. The European Qualifications Framework (EQF) also is heavily focused on skills and knowledge but makes no explicit reference to any aspect of the affective domain ( https://ec.europa.eu/ploteus/content/descriptors-page). Encouragingly, the Organisation for Economic Co-operation and Development's (OECD) “Learning Compass 2030” does identify values and attitudes as explicit points of a compass of future education ( http://www.oecd.org/education/2030-project/).
This demarcation, however, contrasts with Mottet (2015), who argues from a neuroscience perspective that the connection between the cognitive and affective domain is so implicit and strong there is no need to pursue its independent description. Rather than considering them intertwined, the model of an educational “triangle” with three sides (skills, knowledge, and affect) supporting each other is offered as an alternative model. The argument for teasing out such threads is to encourage attention to a more obvious inclusion of affective learning in curriculum design. Given recent and international concerns with poor standards of practice provision (Mid Staffordshire NHS Foundation Trust, 2013; Richards & Borglin, 2019), the time for an exclusive focus on skills and knowledge development may be near. Ongoing debates of what constitutes fundamental care (Kitson et al., 2013) and the way it is taught (Feo et al., 2018) argue for a more overt requirement for education in affective learning to be provided equally alongside skills and knowledge.
Describing Affective Learning
When Krathwohl et al. (1964) completed volume two of Bloom's taxonomy, they noted the work was more intellectually challenging than the development of the cognitive domain. Describing affective learning outcomes requires educators to consider a person's “…interests, attitudes, appreciations, values, and emotional sets or biases” (Krathwohl et al., 1964, p. 7). The mere fact that some of these outcomes lend themselves more to description than definition suggests there is a greater challenge to educational design than that posed by cognitive goals. The five levels of the affective domain are receiving, responding, valuing, organization, and characterization, which come together through a process of internalization (Krathwohl et al., 1964). Internalization describes how each level is related along a continuum of feelings, attitudes, and behaviors.
Connecting affective learning outcomes across a nursing curriculum is arguably a significant challenge, one that is made more difficult without a coordinated and considered preparation of teachers, educators, and academic staff. The argument to first recruit and then reeducate teachers to the benefit and approach to affective teaching is threefold. First, the demand for health care professionals with resilience, capability, and adaptability requires graduates with sound insights to their own internal motivations and a degree of self-awareness. Educators must be adequately prepared to take their own personal affective development journey. Throughout the project described in this article, the inclusion of fellow educators from the beginning of the video production was very effective at enabling reflection on teaching practices.
Second, although there are already champions of affective learning in nursing education, with some making profound and lasting impressions on students, they often are doing so despite any specific regulatory or educational mandate. Such educators need to know their efforts are important, supported, and expected by powerful and influential institutions. Thweatt and Wrench (2015) argue that establishing base attitudes toward affective learning is essential to the willingness and ability to be a lifelong learner. This expectation should apply equally to the educators themselves.
Finally, rapid advances in technologies such as 360° video and augmented reality are providing educators with a new suite of exciting tools for learning, each with the potential to elevate and engage students so they can operate at higher levels of participation. Koch (2014) notes that the time for nurse educators to become comfortable and competent with new forms of e-learning has arrived.
Designing 360° Video to Reflect the Affective Domain
While a foray into the creation of various 360° videos using increasingly sophisticated but affordable 360° cameras can be an engaging and fun activity for educators, caution is offered that without careful scripting and a well-defined set of learning outcomes to guide the production, the result may be less than useful. When considered individually, each level of the affective domain represents a characteristic that nurses or nursing students ideally should have or should be working toward, much like the hierarchy expected between recall and justification in the cognitive domain. When considered as a connected and taxonomic path, the levels provide as much guidance and instruction for educators in designing learning activities as do widely available descriptions of cognitive and psychomotor development. This article provides an example of one such approach that may be a useful starting point for other educators who wish to implement affective education.
The Operating Room
Experiential or clinical placement in the operating room can be a wonderful experience for students from a range of health professions, such as medicine, nursing, physiotherapy, and paramedicine. However, this experience comes with its own set of unique challenges. The vulnerable patient, the sterile and almost alien environment, a raft of similarly dressed and seemingly task-focused professionals speaking in a language of unique acronyms conspire to make the room an uncertain and often uninviting place to the uninitiated. Set amongst other sensory challenges of blood, smell, and anxiety, the task of educators to prepare students for this experience is difficult. Knowing and anticipating the impact that a room placement may have on their learning, students understandably may have some trepidation. The guiding principle of room—to not contaminate anything that is sterile—can leave students much more focused on where to stand and what not to touch than learning about the very real, person-oriented intervention taking place.
To begin the 360° VR experience, the student is seated on a swivel chair and asked about concerns of motion sickness; when ready, the student dons the VR headset. Playback of the video through the attached computer is initiated by the educator. The video begins with the student taking the perspective of a patient, lying in bed while being wheeled through the hospital on the way to the operating room. Once inside the operating room, the “patient” is moved onto the operating table and welcomed by a nurse in scrubs who explains who the health care providers are and asks if they can respond to any concerns. The anesthetist then describes his or her role before gently placing a mask over the patient's face, at which point the experience fades to black.
Shortly after waking, the student begins the second part of the 360° video and is now in the operating room as an actual student on placement. Greeted by the attending circulating nurse, the student is oriented to the operating room and introduced to each of the people who are normally present—the scrub nurse, anesthesiologist, nurse anesthetist, and surgeon. This is an asynchronous activity; the student is essentially watching a movie. Importantly, though, with sophisticated scripting and carefully sign-posted visual and auditory cues to guide the student, the student often forgets he or she is communicating within a video recording, such is the level of immersion that a well-crafted 360° VR experience can provide.
Applying Affective Learning
The first consideration to designing a 360° VR is to have some mechanism to prepare students for learning, to be engaged, and to be ready to “receive.” If students have never used a VR headset before, their first instinct understandably is to look all around at the roof, floor, or window; this response in fact should be encouraged as a part of the scripted experience. This visual exploration in the first few seconds of beginning a 360° VR experience is an important precursor to receiving; in essence, the student is being prepared to receive the initial learning stimulus. In designing a 360° VR experience, it is suggested to use the first few moments of an activity for the sole aim of awareness building. For this reason, it is important that critical learning elements are not placed too early in the script. Without this consideration, the risk is that the student, distracted by the VR world, will not be focused and ready to “receive” the next intended learning outcome.
As the first level of the taxonomy, receiving therefore informs two essential production considerations. The first is to ensure the student is aware that a deeper more engaging episode learning is coming, and the second is understanding when the student is ready to move to the next level of learning. Affective learning requires a different awareness on the part of the educator to gauge if the student is ready to move on and receive the rest of the lesson. As willingness and engagement are key to most successful episodes of learning, one of the most significant impacts of using 360° VR technology lies in its capacity to engage and then stimulate a response from the student.
Well-designed forms of VR education are an interactive experience; the student generally is not passive in their interaction with the environment. The room experience described here was scripted over many iterations and trials. Actors playing the roles of clinicians would direct commentary and questions to the student and then pause to allow some form of response. A fascinating observation during the experience is to watch the student who is nodding affirmatively (responding) and enthusiastically to the “electronic teachers” in the VR world, such is the immersion possible. Responses such as this reflect what Krathwohl et al. (1964, p. 120) describe as “…acquiescence and compliance,” key attributes at this level of the taxonomy.
It was hoped that the students in this project would achieve at least the level of valuing. Valuing, which comprises three principles—acceptance, preference, and commitment—is the encouragement of students to see the worth of something (Krathwohl et al., 1964). The intended values for this activity were to establish some form of empathy for someone going to the operating room, to reduce the anxiety of attending the operating room as a student, to encourage awareness of clinical roles, and to foster a degree of confidence in students who were attending the operating room for the first time. The approach taken by the teaching team was to encourage students to reflect on and write down their perceptions of going to the operating room prior to and after the 360° VR experience. In this way, a baseline of feelings was established, which then was challenged by the 360° VR experience itself.
The description of the level of organization in the affective domain by Krathwohl et al. (1964) includes an element of conceptualization, arguably a significant philosophical step up from the attribute of valuing. This is due to the more intellectual measurement of how students may be organizing their internal value system, a more abstract and challenging stage of development. In the example presented in this article, students move beyond receiving, responding, and valuing their virtual operating room experience to a broader consideration of concepts such as empathy. Jones-Schenk (2016) wrote “…empathy must be exercised to be maintained, much like a muscle” (p. 444).
The inclusion of an experience designed to evoke a level of empathy was a way to prepare students to consider the human face and function of the operating room. Although they may be attending for the first time as students, reminding them that it also could be the first time the patient has been in the operating room is a way to push for a deeper set of reflections. Careful design of 360° and VR scenarios can equip students with the ability to further scaffold and structure insights and begin to organize their own value system. The highest level of affective learning is characterization (of values), an approach or attitude whereby students consistently apply the affective learning attributes they have to new and alternative situations. This is a time where educators can aim for even higher-level goals or expectations; for example, the ability of a student to carry forward the awareness of a patient experience of the operating room to other equally demanding clinical environments. Intensive care units or emergency departments are settings in which patient outcomes often are measured solely on the application of technical skills and applied knowledge, possibly with less time to consider thoughts and feelings. Ironically, such environments often are even more likely to require consideration of the values and feelings of others.
Conceptualizing the way affective learning can be delivered and assessed has been a challenging issue for some time. Technology, such as 360° video used in VR format, can provide a deeply immersive, reproducible, consistent, and scaffolded approach to affective learning. The focus of this innovation was to prepare students in health sciences to attend the operating room and to give them two affective learning activities. The first goal was to develop empathy from the patient's perspective, and the second goal was to encourage the students themselves to realize their own affective learning needs and ideally reduce their anxiety associated with attending the operating room for the first time. The key to this learning innovation was to develop a 360° video informed by each stage of the affective domain. Adoption of new technologies that can create innovative, engaging, and reproducible learning activities is creating new approaches to old challenges. The benefit of embedding the affective domain with greater transparency and detail is one step toward more empathic and considered health professionals.
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